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NEBVOUS  DISEASES: 


THEIR 


DESCRIPTION  AND  TREATMENT. 


BY 


ALLAN  McLANE  HAMILTON,  M.D., 

FELLOW  OF  THE  NEW  YORK  ACADEMY  OF  MEDICINE  ; 
ONE  OF  THE  ATTENDING  PHYSICIANS  AT  THE  EPILEPTIC  AND  PARALYTIC  HOSPITAL, 

BLACKWELL'S  ISLAND,  NEW  YORK  CITY  J 

AND  A  T  THE  OUT-PATIENT  DEPARTMENT  OF  THE  NEW  YORK  HOSPITAL  ; 

MEMBER  OF  THE  AMERICAN    NEUROLOGICAL  ASSOCIATION, 

ETC.  ETC.  ETC. 


WITH    FIFTY-THREE    ILLUSTRATIONS. 


PHILADELPHIA: 

HENEY     O.     LEA. 

1878. 


W  L  ( 00 
\\  2 i 1  ^ 


Entered  according  to  Act  of  Congress,  in  the  year  1878, 

HENRY    C.    LEA, 
in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


PHILADELPHIA : 
COLLIX8,     PRINTER, 

700  Jayne  Street. 


FORDYCE    BARKER,  M.D., 


JOHN  T.  METCALFE,  M.D 


CONTENTS.  ix 

CHAPTER  XIII. 

CEREBRO-SPINAL  DISEASES. 

PAGE 

Cerebro- Spinal  Meningitis — Cerebro- Spinal  Sclerosis — Alcoholism — Acute 
— Chronic — Hydrophobia — Hysteria — Hystero-  Epilepsy —  Catalepsy  343-3  9 

CHAPTER   XIV. 

CEREBRO-SPINAL  DISEASES  (CONCLUDED). 

Chorea — Paralysis  Agitans — Exophthalmic  Goitre    .  393-412 

CHAPTER   XV. 

DISEASES  OF  THE  PERIPHERAL  NERVES. 

Neuralgia,  facial,  cervico-occipital,  cervico-brachial,  intercostal,  or  pleuro- 
dynia — Sciatic — Crural,  visceral,  ovarian,  urethral,  renal,  etc.  .  419-443 

CHAPTER    XVI. 

DISEASES  OF  THE  PERIPHERAL  NERVES  (CONTINUED). 

Neuritis — Anaesthesia — Tumors  of  Nerves         .....     444—452 
CHAPTER    XVII. 

DISEASES  OF  THE  PERIPHERAL  NERVES  (CONTINUED). 

LOCAL  PARALYSIS — Facial  paralysis — Traumatic  paralysis — Diphtheritic 
paralysis  ...........  453-469 

CHAPTER   XVIII. 

DISEASES  OF  THE  PERIPHERAL  NERVES  (CONCLUDED). 

Lead  Poisoning — Functional  Spasm — Tetany — Functional  spasm  with 
voluntary  movements — Reflex  spasm — Facial  spasm  without  pain — Torti- 
collis— Professional  Cramp — Writer's  Cramp — Dancer's  Cramp — Tele- 
grapher's Cramp,  etc.  etc 470-489 

FORMULAS  .....     490-505 


LIST  OF  ILLUSTRATIONS. 


FIG-  PAGE 

1.  Dr.  Seguin's  surface  thermometer        .  .  .  .  .22 

2.  Sieveking's  aesthesiometer        ......         23 

3.  Diagram  for  making  records     ......         52 

4.  Beard  and  Rockwell's  piesmeter  .  .  .  .  .26 

5.  Mathieu's  dynamometer  ......         26 

6.  The  author's  dynamometer       ......         27 

7.  Loring's  ophthalmoscope  ......         28 

8.  The  author's  gas  cautery  .  .  .  •  .  .33 

9.  Osteoma  of  dura  mater  ....    (Lancereaux)         39 

10.  Tuberculous  matter  about  a  vessel        .  .     (Cornil  and  Ranvier)         60 

1 1 .  Distended  perivascular  spaces  with  atrophy     .  .       (Fothergill)         78 

12.  The  topography  of  lesions        .  .  .  .  .  .97 

13.  IVIiliary  aneurisms         .......          98 

14.  Multiple  lesions  with  tongue  atrophy   .  .  .  .  .102 

15.  Instrument  for  applying  heat  and  cold  .  .  .  .111 

16.  Tissue  changes  in  softening       ......       158 

17.  Handwriting  of  an  agraphic  patient      .  .  .     (Bourneville)       166 

18.  Handwriting  of  agraphia  and  cerebro-spinal  sclerosis   .  .  .       166 

19.  Location  of  island  of  Reil        ....         (Bateman)       168 

20.  External  indication  of  island  of  Reil   .  .  .   (after  Turner)       179 

21.  Choked  disk     .....  (after  Leibreich)       188 

22.  Tubercular  deposit        .  .  .  .  .  .  .191 

23.  Sarcoma  ........       191 

24.  Gumma  .  .  .  .  .  .  .  .191 

25.  Psammoma       .  .  .  .  .  .  .  .       191 

26.  Encephaloid      .  .  .  .,  .  .  .  .192 

27.  Glioma  .  .  .  .  .  .  .  .192 

28.  Cerebellar  aneurism      .  .  .  .  .         (Bristowe)       197 

29.  Deformity  of  hand  in  cervical  pachymeningitis  .  (Charcot)       206 

30.  The  consequences  of  spinal  section        .  .  .  .  .214 

31.  Changes  in   muscular    tissue   in    antero-spinal   paralysis   of   infancy 

(Duchenne)  .......       245 

32.  Changes   in   muscular   tissue   in   antero-spinal    paralysis   of   infancy 

(Duchenne)  .  .  .  .  .  .  .       245 

33.  Changes   in   muscular  tissue   in   antero-spinal    paralysis   of    infancy 

(Duchenne)  .......       245 


Xii  LIST    OF    ILLUSTRATIONS. 

FIO.  PAOE 
34.  Changes  in   muscular  tissue   in   antero-spinal    paralysis   of   infancy 

(Duchenne)              .                          .....  245 

85.  Antero-spinal  paralysis  of  adults          .             .             .            (Seguin)  248 

36.  "Main  engriffe"         .....           (Roberts)  256 

37.  Atrophy  of  left  shoulder          ......  258 

88.  Partial  facial  atrophy  .  .  .  .  .  .  .267 

89.  The  spinal  curve  in  pseudo-hypertrophic  paralysis       .  .  .272 

40.  Appearance   of    muscular    tissue    in    pseudo-hypertrophic    paralysis 

(Charcot)     ........  274 

41.  Appearance  of  trophic  bone-changes  in  locomotor  ataxia       (Charcot)  283 

42.  The  course  of  posterior  nerve-roots      .             .             .             (Clarke)  285 

43.  Pathological  changes  in  locomotor  ataxia  and  antero-lateral  sclerosis 

(after  Charcot)         .......  292^ 

44.  Lateral  sclerosed  patches          .             .             .             .          (Charcot)  294 

45.  Region  of  endemic  tetanus  on  Long  Island       ....  301 

46.  The  pathology  of  hysteria        ......  382 

47.  Hystero-epilepsy           .......  386 

48.  Dr.  Yeo's  case  of  exophthalmic  goitre              .             .             .    (Yeo)  413 

49.  Chart  for  the  application  of  electricity  •           .             .    (after  Henle)  440 

50.  Trophic  change  of  the  skin       ......  445 

51.  Sarcomatous  neuroma  .....         (Foucault)  452 

52.  Wire  hook  for  the  treatment  of  facial  paralysis             .             .             .  458 

53.  Reflex  spasm  from  genital  irritation     .  .  .  .-  .481 


NERVOUS  DISEASES. 


INTRODUCTION'. 

HINTS  IN  REGARD  TO  METHODS  OF  EXAMINATION 
AND  STUDY. 

IN  beginning  our  consideration  of  the  diseases  which  are  to  form  the 
subject  of  the  succeeding  pages,  it  is  well  to  start  with  systematic  rules 
for  investigation,  and  it  is  of  paramount  importance  that  we  should  pursue 
some  plan  which  will  enable  us  to  avoid  confusion,  and  assist  us  in  making 
an  accurate  diagnosis  by  exclusion.  One  of  the  greatest  misfortunes  that 
can  happen  to  the  student  is  the  possession  of  a  large  accumulation  of 
badly-arranged  facts,  which  are  stored  away  in  the  brain,  like  odds  and 
ends  in  a  garret.  I,  therefore,  propose  a  scheme  to  be  used  in  the  exami- 
nation of  patients,  and  would  add  a  word  of  caution  in  regard  to  the  error 
many  of  us  make  in  too  readily  accepting  and  isolating  nervous  symptoms 
as  distinct,  which,  after  all,  may  be  expressions  of  some  general  disorder. 

We  are  to  determine  the  existence  and  relation  of  disorders  of  motility 
and  sensation,  as  well  as  mental  symptoms,  defects  of  speech,  sight,  or 
hearing,  together  with  the  causes  which  enter  into  their  production. 

EXAMINATION  OF  THE  PATIENT — Sex,  age,  temperament,  appearance, 
duration  of  present  disease,  existence  of  complicating  maladies,  previous 
history,  hereditary  predisposition,  habits. 

SYMPTOMATOLOGY — Motility,  location  of  loss  or  increase  (one  side  or 
one-half  of  body?),  groups  of  muscles  or  single  muscles,  face,  trunk,  or 
extremities,  lateral  or  bilateral,  symmetrical  or  unsymmetrical,  loss  or 
exaggeration  of  electro-muscular  contractility,  fibrillary  contractions,  mus- 
cular power,  deformities  or  contractures ;  atrophy  or  hypertrophy,  general 
or  partial ;  spasms,  tonic  or  clonic,  attended  or  unattended  by  loss  of  con- 
sciousness ;  pain ;  degree  of  violence. 

TREMOR. — Local  or  general,  increased  or  controlled  by  will,  "  fine"  or 
"  coarse;"  time  of  day,  continuous  or  at  intervals;  subsidence  or  continu- 
ance during  sleep. 

INCOORDINATION  of  upper  or  lower  extremities,  variety  of  action  in 
which  it  occurs ;  gait ;  aggravation  by  closure  of  eyes  ;  loss  of  muscular 
ense  ;  loss  of  locating  power. 

2 


18  INTRODUCTION. 

VERTIGO. — Variety  ;  concomitant  phenomena. 

SENSATION — General  or  partial  anaesthesia ;  dysaesthesia  or  hyperaes- 
thesia ;  condition  of  reflex  excitability ;  susceptibility  to  painful  impres- 
sions ;  temperature  ;  tactile  sensibility ;  sensibility  to  pressure ;  pain, 
localized  or  general ;  character  of  pain,  neuralgic,  terebrating,  dull,  or 
paroxysmal ;  time  when  aggravated  ;  its  associations ;  time  of  transmission. 

DISORDERS  OF  ORGANS  OF  SPECIAL  SENSE. 

Eyes. — Nystagmus,  strabismus,  conjugate  deviation  (see  article  Cere- 
bral Hemorrhage),  retinal  changes,  pupillary  changes,  ptosis,  diplopia, 
amaurosis. 

Ear. — Deafness,  subjective  noises,  discharge. 

Speech. — Aphasia,  slow  speech,  clumsy  speech,  ataxia,  loss  of  speech 
(mutism). 

PSYCHICAL  DISORDER — Illusion,  hallucination,  delirium,  mania,  me- 
lancholia, delusions,  loss  of  memory,  loss  of  consciousness,  imbecility,  idiocy, 
excitability,  dementia. 

MISCELLANEOUS. — Character  of  cutaneous  surface,  changes  in  tempera- 
ture, variation  in  salivary  secretions,  changes  in  pigmentation  and  appear- 
ance of  hair,  perspiration,  etc. 

EXCITING  CAUSE  ;  DIAGNOSIS  ;  TREATMENT. 

This  list,  though  imperfect,  will,  I  think,  enable  the  observer  to  pursue 
a  systematic  course  in  examining  his  patient.  He  should,  at  the  same 
time,  take  careful  notes  for  future  reference,  so  that  variations  in  the 
symptoms  and  changes  of  treatment  may  be  remembered. 

Before  leaving  the  subject  of  examination,  I  wish  to  refer  to  the  value 
of  j>ost-mortem  examination  and  microscopical  investigation  of  the  morbid 
anatomical  changes.  These  subjects  belong  more  properly  to  special  works 
upon  pathology  and  microscopy,  but  it  may  not  be  amiss  to  add  a  few  hints 
to  those  already  given  in  regard  to  certain  important  steps  to  be  taken.  In 
removing  the  calvarium  the  thickness  of  the  cranial  bones  should  be  noted, 
»s  well  as  the  condition  of  the  diploe;  but  extreme  care  should  be  employed, 
in  sawing  through  the  bone,  not  to  wound  the  meninges  and  brain-sub- 
stance beneath ;  for  the  saw-teeth  may  unexpectedly  tear  through,  lace- 
rating and  injuring  these  parts,  so  that  they  may  be  almost  useless  for  sub- 
sequent examination.  After  the  skullcap  has  been  removed,  the  observer 
should  be  on  the  lookout  for  Pacchonian  bodies,  and  ready  to  recognize  any 
adventitia  that  may  be  attached  to  the  dura  mater.  The  condition  of  the 
longitudinal  sinus  and  veins  which  are  contained  in  the  dura  mater  should 
be  examined  as  to  their  fulness,  etc. ;  the  thickness,  vascularity,  color,  and 
opacity  of  their  tissue  should  also  be  carefully  noted  and  then  an  incision 


POST-MORTEM    EXAMINATFON.  19 

may  be  made,  and  this  membrane  slit  up  with  a  pair  of  blunt-pointed 
scissors,  or  it  may  be  cut  around  at  the  level  of  the  saw  cut.  The  arach- 
noid and  pia  mater  are  then  to  be  inspected:  the  existence  of  effusion, 
either  serous,  purulent,  or  bloody;  and  the  presence  of  granular  deposit  or 
vascular  changes  noted.  The  brain  should  be  lifted  back,  and  the  cranial 
nerves  carefully  cut  as  near  as  possible  to  their  points  of  exit  from  the 
skull,  the  optic  first,  and  then  the  carotid  arteries  and  posterior  nerves  ; 
next  the  tentorium,  and  finally  the  other  nerves,  vertebral  arteries,  and 
the  spinal  cord  as  low  down  as  possible,  taking  care  not  to  make  pressure 
by  insinuating  the  finger  into  the  foramen  magnum.  The  brain  may  then 
be  removed.1  If  it  is  desired  to  remove  the  cord,  the  skin  and  muscular 
tissue  of  the  .back  should  be  divided  and  thrown  back,  and  the  spinous 
processes  and  laminae  exposed.  These  latter  should  be  sawn  through  on 
each  side  and  carefully  raised  by  the  blade  of  the  chisel.  When  the  brain 
is  removed,  it  should  be  placed  with  the  base  downwards,  and  the  appear- 
ance of  the  convolutions  noted,  the  membranes  having  been  removed. 
Evidences  of  pressure  are  to  be  looked  for,  and  color  is  to  be  noticed,  as 
well  as  the  depth  of  the  sulci  and  superficial  evidences  of  softening  or  scle- 
rosis, morbid  growth,  and  infiltration.  The  organ  may  be  turned  over, 
and  the  arteries  at  the  base  inspected  in  regard  to  the  existence  of  anom- 
alies, aneurisms,  degeneration,  thrombosis,  or  embolism.  The  fissure  of 
Sylvius  may  be  gently  examined,  and  the  middle  cerebral  traced  up  for 
some  distance.  The  cranial  nerve-trunks  are  to  be  carefully  noticed,  and 
if  any  suspicious  appearance  is  observed,  a  section  may  be  removed  for 
microscopical  examination.  The  crura  and  pons  are  to  be  examined  care- 
fully for  softening  extravasations  and  the  like,  and  the  appearance  of  the 
basal  parts  of  the  hemispheres  next  noticed.  The  brain-substance  may 
be  inspected  after  cutting  through  the  corpus  callosum,  and  turning  each 
hemisphere  gently  back,  or  by  slicing  off  the  brain-substance  with  a  broad 
sharp  knife  previously  dipped  in  water  or  alcohol,  so  that  the  white  matter 
may  be  examined  at  different  levels.  The  condition  of  the  ventricles  should 
be  noticed  as  to  the  effusion  of  serum  or  blood.  The  parts  at  the  floor  of  the 
lateral  ventricles  deserve  special  study,  and  the  corpora  striata  should  be 
inspected  very  attentively,  the  extra-ventricular  and  intra-ventricular  parts 
being  carefully  sliced.  The  fulness  of  the  vessels  in  the  deep  parts  of  the 
brain,  the  existence  of  patches  of  softening  or  induration,  and  the  pressure 
of  cysts,  tumors,  or  morbid  growths  should  be  looked  for.  It  is  always 
advisable  in  cases  where  aphasia  has  been  a  symptom  during  life,  to  care- 
fully inspect  the  anterior  convolutions,  particularly  the  third  frontal, 
which  is  the  generally  acknowledged  seat  of  the  lesion,  and  we  may  do  this 
by  entering  the  fissure  of  Sylvius. 

It  is  hardly  necessary  to  allude  to  the  importance  of  carefully  examining 
the  medulla  and  the  roots  of  the  various  cranial  nerves,  and  for  this  pur- 

1  Removal,  en  masse,  of  the  brain  and  its  membranous  coverings  should  never 
be  attempted ;  the  result  of  such  a  procedure  being  mechanical  injury,  which 
reduces  the  organ  to  a  pultaceous  mass,  rendering  it  unfit  for  examination. 


20  INTRODUCTION. 

pose  it  is  advisable  to  remove  such  parts  as  are  wanted  for  subsequent 
microscopical  examination.  The  cord  must  be  examined  critically  in  cases 
of  spinal  disease,  and  the  same  directions  are  given  for  its  inspection.  Sus- 
pected portions  may  be  cut  out  and  laid  aside,  care  being  taken  to  secure 
as  much  of  the  external  roots  as  possible.  In  special  cases  nerve  trunks 
or  peripheral  nerves  may  be  exsected  for  future  examination,  and  in  cases 
attended  by  muscular  atrophy  and  degeneration  it  is  well  to  ascertain  the 
morbid  changes  in  the  muscles.  If  we  desire  to  use  the  microscope  it  is 
generally  necessary  to  harden  the  tissues,  although  fresh  nervous  substance 
may  be  teased  apart  in  glycerine  or  serum  by  needles  prepared  for  the  pur- 
pose. If  we  prefer  the  first  method  we  may  put  such  masses  of  the  brain 
or  cord  as  we  desire  to  harden  into  Miiller's  fluid,  which  is  prepared  as  fol- 
lows : — 

R.  Potass,  bichromat.  50  grammes, 

Sodic  sulphate,  20  grammes, 

Water,  50  cubic  centimetres : 

Or,  what  is  better,  the  solution  recommended  by  Prof.  J.  W.  S.  Arnold,  of 
the  Medical  Department  of  the  University  of  the  City  of  New  York  : 

R.   Ammon.  bichromate,  11  grammes, 
Methyl  alcohol,  320  grammes, 
Water,  640  grammes. 

Care  should  be  taken  not  to  secure  too  large  specimens,  as  they  do  not 
harden  thoroughly,  the  exterior  becoming  hard  while  the  interior  is  dif- 
fluent and  useless.  They  should  be  left  in  this  solution  for  a  month  or  six 
weeks,  but  not  till  they  become  granular  or  cheesy,  for  then  it  is  impossible 
to  make  a  good  section,  as  the  tissue  is  apt  to  crumble  under  the  razor. 
At  the  end  of  this  time,  or  when  the  tissue  is  quite  firm,  it  may  be  removed 
and  placed  in  a  fifty  per  cent,  solution  of  alcohol  and  water.  The  speci- 
men may  be  examined  to  test  its  hardness  by  making  sections  with  a  razor 
from  time  to  time.  If  a  very  thin  section  can  be  made  with  a  moistened 
ra/or  without  parting,  adhesion,  or  crumbling,  it  may  be  considered  to  be 
in  fit  condition  for  removal  from  the  hardening  solution.  A  solution  of 
bichromate  of  ammonium,  1/i  grains  to  the  ounce  of  water,  is  an  excellent 
hardening  solution,  in  which  the  specimen  may  remain  until  it  has  been 
uniformly  saturated,  and  hardening  has  commenced,  and  then  it  is  to  be 
removed  and  placed  in  a  solution  of  chromic  acid,  two  grains  to  the  ounce 
of  water,  where  it  is  to  remain  until  hard  enough  for  cutting.  This  is  the 
process  recommended  by  Dieters.  The  specimens  may  be  taken  out  and 
kept  for  use  in  dilute  alcohol  till  they  are  needed. 

When  the  hardened  tissue  is  to  be  examined,  it  is  to  be  imbedded  in 
pith  or  paraffine,  and  either  placed  in  a  section  cutter,  or  held  in  the  hand. 
By  practice,  this  latter  procedure  becomes  quite  easy,  and  very  thin  sections 
may  be  made.  A  piece  of  brain  or  a  length  of  cord  of  a  convenient  size  is 
surrounded  by  elder  pith  previously  prepared  to  receive  it,  and  bound  in 
place  by  a  string  or  piece  of  fine  copper  wire.  When  moistened,  the  pith 
swells  so  that  the  tissue  receives  uniform  pressure  and  support.  If  the 


MICROSCOPIC    EXAMINATION.  21 

paraffine  process  is  to  be  employed,  the  tissue  is  to  be  carefully  dried  and 
placed  in  a  small  paper  mould  which  is  afterwards  filled  with  melted  paraf- 
fine, which  should  not  be  too  hot,1  and  care  should  be  taken  to  exclude  air- 
bubbles — when  cool  and  solid  the  upper  part  of  the  paper  may  be  torn 
away,  and  the  specimen  is  ready  for  cutting.  A  flat  razor  is  the  best 
instrument  of  which  I  knowr  for  ordinary  work.  Its  blade  should  be  dipped 
in  a  saucer  containing  alcohol  placed  conveniently  by,  and  the  face  of  the 
section  should  be  moistened  from  time  to  time.  The  individual  holding 
the  mould  firmly  between  the  thumb,  forefinger,  and  second  finger  of  the 
left  hand,  cuts  away  a  portion  of  mould  and  tissue  so  that  a  level  surface  is 
left  exposed ;  then,  with  moistened  razor,  he  plants  the  blade,  and  slowly 
cuts  a  thin  slice  of  paraffine  and  tissue  together ;  this  is  removed  by  a 
camel's  hair  brush  which  has  been  dipped  in  alcohol,  and  next  dropped 
into  a  small  vessel  containing  dilute  alcohol,  and  then  placed  in  the  stain- 
ing fluid,  which  may  be  the  following  : — 

R.  Carmine  (pure),  gr.  xx, 

Liq.  ammoniae,  q.  s.  ut  dissolve, 

Glycerinae, 

Aquae,  aa  51). — M. 

After  being  allowed  to  soak  for  several  hours  or  days,  the  sections  are 
removed  and  dropped  into  wrater  slightly  acidulated  with  acetic  acid.  They 
are  now  to  be  placed  in  absolute  alcohol  for  a  short  time,"  and  afterwards 
placed  in  oil  of  cloves  until  they  become  transparent.  A  perfectly  clean 
slide  is  procured,  upon  which  one  of  them  is  placed  and  a  drop  (not  too 
large)  of  Canada  balsam  is  next  applied.  It  is  then  covered  by  a  thin 
glass  cover,  care  being  taken  to  exclude  air-bubbles.  Various  preparations 
are  used  to  stain  nervous  tissues ;  for  instance,  a  solution  of  chloride  of  gold 
will  stain  the  nerve  fibres,  and  render  them  more  distinct ;  hsematoxylin 
and  osmic  acid  are  also  used,  and  the  black  anilin  process  of  Herbert  Major3 
produces  the  most  beautiful  results.  These  manipulations,  however,  are  out 
of  place  here,  and  I  would  refer  the  reader  to  any  one  of  the  excellent  text- 
books that  have  appeared  during  the  past  few  years  for  more  explicit  direc- 
tions. 

It  is  often  necessary  to  make  sections  in  all  possible  directions  and  posi- 
tions, and  to  do  this  properly  the  microscopist  must  not  only  have  practice 
but  patience  and  care.  It  is  advisable  to  procure  at  least  two  objectives, 
one  for  coarse  appearances,  and  the  other  for  minute  changes,  and  I  would 
suggest  that  these  should  be  an  "  inch"  and  a  "quarter  inch." 

1  I  have  recently  used  metallic  bottle  caps,  which  may  be   easily  procured. 
AVhen  the  paraffine  is  cool  the  metal  may  be  stripped  off. 

2  West  Riding  Reports,  vol.  v. 


22  INTRODUCTION. 


INSTRUMENTS  USED  FOR  THE  DIAGNOSIS  OF  NERVOUS 

DISEASE. 

It  is  essential  that  we  should  possess  certain  instruments  which  shall  be 
more  valuable  and  exact  than  our  unaided  senses,  so  that  we  may  not  only 
make  reliable  investigations,  but  compare  from  time  to  time 
Fig.  1.         guch  variations  as  may  occur  in  the  patient's  condition. 

Those  I  propose  to  describe  are  intended  for  examinations 
of  temperature  and  sensory  changes,  and  for  the  detection  of 
altered  motility. 

THE  THERMOMETER There  are  several  instruments 

made  for  the  purpose  of  determining  variations  in  tempe- 
rature, and  though  some  are  of  extreme  delicacy,  I  do 
not  think  it  will  be  worth  while  to  recommend  them,  as 
they  are  bulky  and  troublesome,  and  are  better  adapted  for 
experimental  purposes  than  actual  clinical  use,  and  among 
these  is  Lombard's  instrument. 

In  Dr.  Seguin's  surface  thermometer  we  possess  an  admi- 
rable little  instrument  for  testing  the  surface  temperature.  It 
has  an  expanded  base,  and  may  be  applied  to  the  surface  of 
the  body,  taking  care  to  cover  the  top  by  a  perforated  piece 
of  thin  rubber  or  leather.  A  coat  or  two  of  shellac  varnish 
to  the  upper  part  of  the  bulb  will  answer  the  same  purpose, 
viz.,  that  of  preventing  the  mercury  from  being  affected  by 
the  temperature  of  the  room.  For  the  determination  of  deep 
temperature  we  may  avail  ourselves  of  any  of  the  good  self- 
registering  instruments.  Two  surface  thermometers  should 
be  used,  one  on  the  sound,  and  the  other  on  the  affected  side 
of  the  body,  and  the  deep  temperature  may  be  taken  at  the 
same  time  for  comparison.  A  new  form  of  surface  ther- 
mometer has  recently  been  made  in  England.  The  glass 
tube  is  spirally  coiled  upon  itself  and  inclosed  in  a  circular 

surface  . 

Thermometer.       box.     This  form  has  the  merit  of  being  unaffected  by  other 

than  the  body  temperature. 

BecquereFs  disks  I  have  found  to  possess  extreme  delicacy,  and  if  pro- 
|)crly  constructed  the  variation  of  a  fraction  of  a  degree  may  be  readily 
appreciated.  They  consist  of  delicate  strips  of  two  sensitive  electro-nega- 
tive and  positive  metals,  imbedded  in  a  handle.  Copper  and  bismuth  are 
generally  used.  By  proper  connections  they  are  put  in  communication 
with  a  delicate  galvanometer  which  registers  the  feeble  thermo-electric 
current  which  is  generated. 

The  vEsTHEsioMETER  was  first  suggested  by  Sieveking,  and  has  since 
been  modified  by  different  individuals.  We  have  several  different  varie- 
ties to  choose  from,  but  no  one  is  better  than  the  original  instrument  of 


THE    jESTHESIOMETER. 


23 


Sieveking,  which  is  also  used  and  recommended  by  Brown-Sequard.     It 
is  made  of  brass  or  steel,  and  very  closely  resembles  a  shoemaker's  mea- 

Fig.  2. 


Sieveking's  JEsthesiometer. 

sure.  The  movable  slide  and  permanent  arms  at  the  end  are  sharp 
pointed.  The  bar  upon  which  the  free  slide  moves  is  ruled  in  centi- 
metres. 

The  other  aesthesiometers  are  mostly  shaped  like  dividers,  and  whether 
they  be  Hammond's  or  Carrol's,  they  are  open  to  the  objection  that  the 
points  are  liable  to  be  unconsciously  approximated  when  the  instrument 
is  removed,  so  that  the  result  of  investigation  is  somewhat  unreliable. 
Carrol's  festhesiometer  has  one  advantage.  The  points  are  bifurcated,  one 
arm  ending  in  a  bulb,  while  the  other  is  sharp,  so  that  analgesia  as  well  as 
anaesthesia  may  be  tested. 


24  INTRODUCTION. 

Dr.  E.  C.  Seguin  has  made  a  very  decided  improvement  upon  the  original 
instrument  of  Sieveking.  He  has  had  it  constructed  of  aluminum,  and  of 
a  smaller  size,  so  that  it  is  light,  and  may  be  easily  carried  in  the  pocket- 
case. 

The  principle  upon  which  the  aesthesiometer  is  constructed  is  the  fol- 
lowing :  The  normal  receptivity  of  tactile  impressions  enables  the  subject 
to  distinguish  two  points  which  are  brought  simultaneously  in  contact 
with  the  skin.  This  susceptibility  varies  greatly  in  different  regions  in 
proportion  to  the  delicacy  of  tactile  sensation  located  therein.  If  there 
be  loss  of  sensation  as  an  accompaniment  or  result  of  nervous  disease,  of 
course  the  distance  between  them  will  have  to  be  increased  before  the 
points  will  be  felt  as  two.  In  hypenesthesia  they  may  be  much  more 
nearly  approximated  and  distinguished  as  two  than  in  the  amesthetic 
state. 

The  average  distance  at  which  the  two  points  of  the  instrument  can  be 
felt  in  the  normal  state  are  as  follows : — 

Point  of  tongue  ........       £  line. 

Red  surface  of  lips 2  lines. 

Palmar  surface  of  third  finger      .  ....       1  line. 

Tip  of  nose 3  lines. 

Metacarpal  bone  of  thumb 4     " 

Skin  of  cheek 5 

Mucous  membrane  of  hard  palate        .....       6 

Dorsal  surface  of  first  finger         ......        7 

Dorsum  of  hand  over  heads  of  metacarpal  bones  .         .       8 

Mucous  membrane  of  gums          ......       9 

Lower  part  of  forehead        .         .         .         .          .         .         .10 

Lower  part  of  occiput 12 

Back  of  hand 14 

Neck  under  lower  jaw 15 

Vertex 15 

Skin  over  the  patella  .         .         .         .         .         .         .16 

Skin  over  the  sacrum  .         .         .         .         .         .         .18 

Skin  over  the  sternum          .......  20 

Skin  over  cervical  vertebrae          ......  24 

Skin  over  middle  of  back  ......  30 

Skin  over  middle  of  the  arm        .         .         .         .         .         .  80     '• 

Skin  over  middle  of  the  leg          .         .         .         .         .         .  80     " 

Certain  precautions  must  be  taken  when  using  the  aesthesiometer,  or 
else  our  examination  will  be  unsatisfactory  in  the  extreme ;  we  must  not 
depend  in  all  cases  upon  the  patient's  statement,  but  exercise  tact  in  getting 
from  him  satisfactory  answers,  and  not  guesses.  There  seems  to  be  in  some 
individuals  a  discouraging  stupidity  which  prompts  them,  in  answer  to  the 
question,  "  How  many  points  do  you  feel?"  to  oftentimes  reply  "Three," 
when  they  know  that  the  instrument  has  but  two  points.  It  is  of  the 
greatest  importance  that  the  patient's  eyes  should  be  covered,  or  that  he 
should  close  them,  as  he  will  unconsciously  look  at  the  instrument  during 
its  application.  It  is  also  of  moment  that  the  points  should  be  fairly  and 


-ffiSTHESIOMETER DYNAMOMETER. 


25 


at  the  same  time  applied  to  the  skin,  one  not  being  pressed  more  than  the 
other,  and  finally,  it  may  be  stated  that  they  should  not  be  applied  at  any 
place  where  the  clothing  has  rubbed  or  chafed  the  surface. 

Fig.  3. 


3 2. 


Diagram  for  making  records. — Roman  numerals  show  anaesthetic  indications,  the  others  nor- 
mal sensibility. 

The  BAR^ESTHESIOMETER  of  Eulenburg,  modified  by  Beard  &  Rock- 
well, has  been  used  as  a  means  for  the  determination  of  the  individual 
sense  of  application  of  weight  which  is  lost  in  various  forms  of  paralysis 
and  anaesthesia.  It  consists  of  a  spiing  which  is  impinged  upon  a  piston, 
both  being  placed  in  a  tube  or  cylinder,  and  the  rod  connected  with  the 
piston  having  a  broad  expansion  at  its  outer  end.  This  disk  is  placed 
upon  the  body,  and  the  spring  impinged,  registers  on  a  scale  the  amount 
of  pressure  made  before  it  is  recognized  by  the  individual. 

The  DYNAMOMETER — Various  forms  have  been  devised,  that  in  general 
use  being  the  invention  of  Mathieu.  It  consists  of  an  elliptical  spring 
which  when  compressed  in  the  hand  registers  upon  an  index  the  force  ex- 
erted. When  the  needle  is  forced  ahead  it  remains  at  the  point  it  had 
reached  when  pressure  was  remitted,  and  the  spring  expands.  Its  disad- 
vantage lies  in  the  inequality  of  pressure  made  at  different  times,  the 
bulky  character  of  the  apparatus,  and  its  inadaptability  to  other  uses. 


26 


Fig  4. 


INTRODUCTION. 

Fiff.  5. 


Board  &  Rockwell's 
Piesmeter. 


Mathien's  Dyaamometer. 

Having  recognized  the  necessity  for  an  instrument 
that  would  meet  the  therapeutical  requirements  not 
possessed  by  those  of  Mathieu  or  Duchenne,  I  have  de- 
vised that  figured  in  the  appended  illustration.  It  con- 
sists of  a  long  glass  tube  (2)  which  dips  into  a  small 
bottle  filled  with  mercury.  In  connection  with  a  bent 
brass  pipe  (3)  is  a  rubber  tube  which  terminates  in  a 
closed  rubber  bulb  (5).  When  this  bulb  is  compressed 
the  mercury  is  forced  up  in  the  glass  tube,  the  end  of 
which  is  closed  (1).  Attached  to  the  tube  is  a  scale 
marked  on  one  side  in  pounds,  and  on  the  other  by 
marks  separated  by  regular  intervals  for  the  purpose  of 
making  comparative  estimates.  As  fifteen  pounds'  pres- 
sure to  the  square  inch  is  required  to  compress  a  given 
body  of  air  into  one-half  its  original  space,  of  course  a 
force  of  fifteen  pounds'  pressure  brought  to  bear  upon 
the  bulb  would  be  required  to  press  the  column  of  mer- 
cury half  way  up  the  scale.  The  advantages  of  this  apparatus  are  the 
following : — 

1.  Its  simplicity. 

2.  The  adaptability  of  the  rubber  bulb  to  receive  pressure  exerted  by 
all  flexors  of  the  hand.     Mathieu's  spring  is  only  acted  upon  by  a  limited 
number;  at  the  same  time,  therefore,  the  test  is  not  a  true  one. 

3.  The  action  of  the  muscles  is  the  same  at  different  times.     The  same 
group  of  muscles  always  being  brought  in  play,  accurate  comparative  tests 
may  be  made  from  day  to  day. 

4.  The  part  receiving  the  pressure  is  of  a  convenient  shape  to  be  used 
by  persons  with  either  small  or  large  hands. 

5.  It  is  accurate  and  always  gives  reliable  indication  of  the  pressure 
brought  to  bear. 

An  instrument  styled  the  dynamograph,  which  is  a  combination  of  the 
dynamometer  and  the  writing  part  of  the  sphymograph,  is  advocated  as  a 
valuable  aid  in  diagnosis.  The  variation  of  imperfectly  sustained  pressure 
is  recorded  upon  a  slowly-moving  card.  I  consider  the  apparatus  a  use- 
less invention,  as  the  results  obtained  must  be  of  the  clumsiest  kind.  In 
fact  no  instrument  but  the  myograph,  of  which  there  are  several  forms, 
is  of  any  use  for  delicate  observation. 


THE    DYNAMOMETER.  27 

I  have  combined  the  rubber  bulb  with  the  drum  of  Marey,  and  am 
enabled  to  obtain  gross  variations  with  tolerable  accuracy.  The  drum  has 
two  pipes,  one  of  which  is  connected  with  the  rubber  bulb,  while  another 
is  attached  to  the  lower  end  of  an  open  glass  tube.  The  bulb-drum  cavity 

Fig.  6. 


The  Author's  Dynamometer. 


and  a  part  of  the  tube  are  filled  with  colored  fluid,  so  that  the  fluid  in  the 
latter  reaches  a  mark  at  about  the  middle  of  its  length.  The  patient  grasps 
the  bulb  and  makes  enough  pressure  to  force  the  fluid  in  this  tube  to  a  mark 
slightly  above  the  other.  The  sustained  voluntary  effort  required  to  keep 
the  fluid  at  this  point  necessitates  some  delicacy  of  muscular  coordination, 
and  should  this  be  impaired  there  will  be  expansion  of  the  drum-head  and 
consequently  irregular  tracings  upon  the  cylinder  of  the  registering^  appa- 
ratus. This  cylinder  should  be  covered  by  a  piece  of  smoked  paper,  and 
the  stylet  placed  in  apposition  thereto. 

In  alcoholic  tremor,  commencing  sclerosis,  and  the  metallic  tremors,  we 
may  obtain  very  beautiful  tracings. 


28  INTRODUCTION. 

THE  OPHTHALMOSCOPE — The  parts  composing  the  ordinary  ophthal- 
moscope are  the  following :  A  concave  mirror  perforated  at  its  centre,  a 
series  of  lenses  by  which  the  refraction  in  the  subject's  or  observer's  eye 
may  be  corrected,  and  a  bi-convex  lens.  The  three  forms  in  common  use 
are  those  of  Liebreich,  Loring,  and  Knapp.  The  two  latter  are  essentially 
alike  in  construction,  and  the  first  is  quite  primitive,  usually  of  bad  con- 
struction and  quite  unreliable. 

Fig.  7. 


Loriug's  Ophthalmoscope. 

Iii  the  examination  with  this  instrument  great  care  should  be  taken  by 
the  observer  to  determine  whether  he  or  his  subject  possesses  errors  of 
refraction,  and  if  so  to  correct  them  with  the  proper  lenses.  In  the  modern 
ophthalmoscope  a  number  of  lenses  are  held  in  a  revolving  disk  beliind 
the  mirror. 

For  more  specific  directions  the  reader  is  referred  to  Dr.  Loring's  ad- 
mirable little  work.1 

To  examine  the  eyes  of  a  patient  properly,  the  observer  may  follow  the 
concise  directions  laid  down  by  Ilutchinson.1 

1  Determination  of  Errors  of  Refraction  with  the  Ophthalmoscope.      E.  G. 
Loring.     Win.  AYood  &  Co.,  N.  Y. 

2  Jonathan  Ilutchinson.     Clinical  Reports  of  London  Hospital  1867-8,  p.  182. 


THE    OPHTHALMOSCOPE.  29 

"  Having  placed  the  patient's  head  in  such  a  manner  that  the  light  (a 
lamp,  candle,  or  gas-light)  is  on  a  level  with  his  temple,  and  slightly  be- 
hind it,  and  his  face,  as  a  consequence,  in  shadow,  the  observer  sits  in 
front  and  applies  the  ophthalmoscope  mirror  to  his  own  eye.  He  should 
keep  both  eyes  open  that  he  may  see  where  the  light  falls,  and  then  move 
the  mirror  until  the  light  falls  full  on  the  pupil  of  his  patient.  In  a  mo- 
ment he  will  perceive  the  first  fact  which  this  instrument  reveals,  that  the 
f'undus  is  not  black,  as  it  has  always  appeared  to  be  before,  but  that  it  is 
of  a  brilliant  fire-red.  He  will,  however,  see  nothing  of  the  fundus  dis- 
tinctly, only  a  general  red  reflex.  Now  at  this  point  the  student  must 
stop  awhile  and  use  his  mirror,  to  inspect,  first,  the  transparency  of  the 
cornea,  and,  next,  that  of  the  lens  and-  vitreous,  and  to  do  this  he  must 
make  the  patient  move  his  eye  in  various  directions.  After  a  little  prac- 
tice he  will  be  able  to  manage  his  light  well,  and  to  throw  it  with  preci- 
sion wherever  he  may  wish,  and  to  keep  it  steadily  on  any  given  part.  At 
a  first  lesson  he  may  even,  with  advantage,  practise  for  a  while  by  illumi- 
nating the  second  button  of  the  patient's  waistcoat.  Tact  in  directing  the 
light  having  been  obtained,  we  may  now  proceed  further.  Instruct  the 
patient  to  look,  not  full  in  your  face,  but  over  one  shoulder ;  if  you  are 
inspecting  his  right  eye,  over  your  left  shoulder.  You  will,  when  he  does 
this,  notice  at  once  that  the  tint  of  the  light  reflected  from  his  fundus  is 
changed,  that  it  is  no  longer  fire-red,  but  canary-yellow.  The  reason  of 
this  is  that  a  different  part  of  the  fundus  is  exposed  to  view,  that,  namely, 
of  the  optic  disk  itself,  which  is  much  lighter  in  color  than  the  rest.  The 
area  of  yellow  is  very  large — occupies,  indeed,  the  whole  of  the  field, 
while  we  know  that  the  disk  itself  is  very  small.  This  proves  that  the 
objects  thus  indistinctly  seen  are  immensely  magnified.  Magnified  by 
what  ?  By  the  patient's  own  eye,  which,  as  we  have  said,  is  equivalent 
to  a  lens  of  one  inch  focus. 

"  Hitherto  we  have  seen  nothing  distinctly,  but  if  the  observer  now 
brings  his  head  very  close  to  his  patient's  face,  he  will  be  able  with  more 
or  less  facility  to  observe  the  details  at  the  bottom  of  the  eye,  the  trunks 
of  vessels  of  the  retina,  the  optic  disk,  etc.  etc.  All  these  will  be  seen 
very  large  indeed,  being  still  magnified  by  the  patient's  eye.  What  he 
sees  now  is  equivalent  to  type  looked  at  through  a  one-inch  lens,  placed 
exactly  one  inch  in  front  of  it." 

Without  entering  into  an  extended  discussion  as  to  the  value  of  this 
instrument  as  a  means  of  diagnosis,  it  will  be  well  to  state  frankly  that  I 
do  not  believe  that  it  possesses  any  positive  value  in  the  diagnosis  of  brain 
disease,  except  where  the  condition  of  the  fundus  is  the  result  of  an  or- 
ganic disease  of  the  brain  or  cord,  or  when  it  is  possible  to  connect  such 
disorders  with  errors  in  refraction. 

In  making  this  statement  I  shall,  perhaps,  find  many  opponents,  but  I 
nevertheless  have  many  powerful  allies.  A  distinguished  author  recently 
took  it  into  his  head  to  call  those  who  differed  with  him,  in  regard  to  the 
diagnostic  value  of  the  ophthalmoscope  in  functional  circulatory  disturb- 
ances, "  pert  pretenders."  How  far  this  accusation  is  true  the  reader 


30  INTRODUCTION. 

may  determine  after  consulting  the  really  convincing  articles  of  Loring,1 
Arbuckle,*  Albutt,  and  others,  which  prove  beyond  question  that  the 
fundus  of  the  eye  is  rarely  any  index  of  the  cerebral  circulation.* 

Bouchut,4  Panas,6  Albutt,'  Hammond,7  Bell,  and  others,  have  written 
extensively,  and  have  furnished  a  large  number  of  clinical  reports  of  oj>li- 
thalmoscopic  changes  coexistent  with  cerebral  tumors,  meningitis,  soften- 
ing, effusion,  cerebral  hemorrhage,  general  paralysis,  locomotor  ataxia 
and  other  forms  of  sclerosis,  epilepsy,  and  the  syphilitic  and  uraemic  neu- 
roses. Hutchinson,8  of  Philadelphia,  in  an  admirable  article,  gives  many 
of  these  cases,  and  shows  the  real  value  of  the  ophthalmoscope,  especially 
when  an  examination  of  the  fundus  reveals  choked  disk  and  optic  neuritis. 
but  I  will  speak  more  fully  in  regard  to  this  subject  when  we  come  to  the 
discussion  of  special  diseases. 


APPARATUS  FOR  THE  TREATMENT  OF  NERVOUS 
DISEASE. 

ELECTRICAL. — Two  forms  of  apparatus  are  required — one  for  the  gal- 
vanic, the  other  for  the  induced  or  Faradic  currents — as  well  us  the 
necessary  electrodes. 

As  we  know,  the  galvanic  current  is  derived  directly  from  a  battery  or 
pile,  the  first  ordinarily  consisting  of  two  elements,  which  are  contained 
in  a  vessel  filled  with  some  exciting  solution,  and  the  latter  of  plates  of 
metal  placed  one  above  the  other,  and  separated  by  disks  of  felt  or  paper 
moistened  with  a  solution  of  salt  or  acid.  This  last  apparatus  is  rarely 
used. 

One  vessel  or  cell  of  the  form  I  first  described  constitutes  a  simple  bat- 

1  Am.  Psychological  Journal,  Nov.  1876. 

2  West  Riding  Reports,  vol.  v.  p.  148. 

3  Dr.  Loring  says,  in  concluding  an  admirable  paper:    "By  the  experiments 
considered  in  the  foregoing  remarks  two  alternatives  are  forcibly  presented  to  our 
mind  :  either  that  the  circulation  of  the  eye  is  not  a  reflex  of  the  circulation  of 
the  brain,  though  derived  directly  from  it ;  and  thus  agents  which  affect  pro- 
foundly the  one  have  little  or  no  influence  on  the  other ;  or,  if  the  retinal  circu- 
lation is  a  reflex  of  the  cerebral,  it  follows  that  the  influence  exerted  on  the  cir- 
culation of  the  brain  by  agents  at  our  command,  remedial  or  otherwise,  is  very 
much  less  than  heretofore  supposed. 

"I  cannot  but  think  that  the  former  alternative  is  the  more  rational,  and  from 
that  very  independence  of  the  two  circulations  there  is  reason  to  fear,  soiiir  as 
functional,  and  especially  mental  diseases,  are  concerned,  that  there  never  will  !><•. 
any  more  than  there  now  is,  any  art  to  read  the  mind's  construction  in  the  eye." 

4  Du  Diagnostic  des  Maladies  du  System  Nerveux   par  1' Ophthalmoscope. 
Paris,  1876. 

5  La  France  Medicale,  Feb.  26,  1876. 

6  Med.  Times  and  Ciaz.,  vol.  i.,  p.  495,  and  seq. 

7  Diseases  of  the  Nervous  System.     New  York,  1876. 

8  Phil.  Med.  Times,  May  8,  1875. 


APPARATUS  FOR  TREATMENT.  31 

tery,  and  two  or  more,  with  the  poles  alternately  connected,  a  compound 
battery. 

Two  qualities  of  electric  force  are  generated  by  a  battery  of  this  kind : 
1.  Quantity;  2.  Intensity.  The  latter  is  the  characteristic  which  makes 
it  valuable  as  a  means  for  the  production  of  muscular  contraction  and 
nerve  stimulation. 

The  Faradic  current  is  derived  from  a  galvanic  cell  primarily,  and  is 
developed  by  its  passage  through  a  coil  of  wire  wound  about  a  central  core 
or  bundle.  Two  currents  are  induced  therein :  one  the  primary  induced, 
the  other  the  secondary  induced.  The  first  is  less  coarse  and  violent  in 
its  effects  than  the  other. 

For  a  more  extended  description  of  electro-physics,  physiology,  and 
therapeutics,  I  would  refer  the  reader  to  any  of  the  works  mentioned  at  the 
foot  of  this  page.1 

For  the  production  of  the  galvanic  current,  we  may  avail  ourselves  of 
either  one  of  the  permanent  batteries  ;  the  cells  of  which  may  be  set  up 
in  the  cellar,  and  the  wires  carried  to  a  proper  board  in  the  office,  con- 
taining apparatus  for  their  selection ;  or  we  may  use  the  ordinary  portable 
galvanic  battery,  many  styles  of  which  are  made. 

I  have  given  the  Leclanche  battery  a  fair  trial,  and  now  do  not  recom- 
mend it,  as  it  is  dirty,  inconstant,  and  rapidly  loses  power.  The  "  maga- 
zine" battery  of  Chester,  in  which  the  peroxide  of  lead  is  substituted  for 
the  black  oxide  of  manganese  in  the  porous  cell,  is  much  better.  The  old 
Daniel's  cell  is,  I  am  convinced,  the  best  of  all,  and  whether  in  the  form 
of  the  Siemens  and  Halske,  or  Hill  modification,  is  all  that  can  be  desired. 

The  table  board  of  Fleming  and  Talbot,  of  Philadelphia,  or  the  arrange- 
ment known  as  the  "  cabinet  battery,"  which  is  made  by  the  Galvano- 
Faradic  Company  of  New  York,  is  admirable  for  office  use. 

The  Galvano-Faradic  Company  of  New  York  construct  a  very  good 
portable  battery  of  thirty-two  cells,  and  I  would  recommend  it  for  general 
use,  as  it  is  admirably  simple  and  effective. 

The  Faradic  instrument  should  be  provided  with  an  attachment  for  the 
slow  or  rapid  interruption  of  the  current,  an  addition  to  the  ordinary  bat- 
tery, which  will  be  found  of  immense  advantage  in  certain  forms  of 

1  Either  of  these  works  will  be  found  practically  useful  to  the  student : — 
Tibbit's  Handbook  of  Medical  Electricity. 
Reynolds'  Clinical  Uses  of  Electricity. 
Althaus's  Electricity,  Theoretical  and  Practical. 
Poore :   A  Text  Book  of  Electricity,  etc. 
Lincoln's  Electro-Therapeutics. 

Beard  and  Rockwell's  Medical  and  Surgical  Electricity. 
Hamilton's  Clinical  Electro-Therapeutics. 
Duchenne's  de  1' Electrisation  localise,  1872. 
Onimus  et  Legros,  Trait6  d'Electricite  Med. 
Benedikt  Elektrotherapie,  1874-5. 
Ziemssen,  Die  Electricitat  in  der  Med.,  1872. 
Besides,  the  -works  of  Rosenthal,  Erb,  Meyer,  Eulenburg,  and  others. 


32  INTRODUCTION. 

paralysis.  The  instruments  of  the  two  firms  I  have  mentioned,  besides 
those  of  Dreschcr  and  Kidder,  are  all  good. 

Two  or  three  cotton-cloth  covered  electrodes  of  different  sizes,  or  flat 
sponges  with  rubber  backs,  with  fine  wire  pole  cords  instead  of  the  flimsy 
gold-thread  connections  in  present  use,  which  oxidize  and  break,  will  be 
needed,  as  well  as  a  bundle  of  fine  wires  held  in  a  handle,  which  is 
known  as  the  electric  brush. 

RUBBER  MUSCLES,  ETC Dr.  Van  Bibber,  of  Baltimore,  has  devised 

a  very  useful  Apparatus  for  the  treatment  of  paralysis,  especially  of  lead 
paralysis.  It  consists  of  a  strap  for  the  hand  or  other  part  which  needs 
support,  and  one  for  a  point  of  attachment  of  the  muscle.  When  properly 
applied,  the  rubber  pipe,  which  takes  the  place  of  the  paralyzed  muscle, 
raises  the  hand,  so  that  the  strain  upon  the  enfeebled  muscle  is  relieved. 
Dr.  Van  Bibber  has  also  used  court  plaster  for  the  treatment  of  ptosis  and 
other  minor  paralyses. 

THE  HYPODERMIC  SYRINGE,  ETHER  SPRAT  APPARATUS,  and  SPINAL 
and  CRANIAL  ICE  BAGS,  should  be  procured  by  every  physician  who  has 
occasion  to  treat  this  class  of  diseases. 

CAUTERIES — Until  a  few  months  ago  the  old  form  of  cautery  was  used 
almost  exclusively.  These  are  of  iron,  and  are  sometimes  platina  covered. 
When  they  are  needed,  they  are  heated  in  the  flame  of  a  Bunsen  burner, 
Russian  blast  lamp,  or  some  such  contrivance,  but  lose  their  heat  very 
rapidly,  and  generally  assume  a  dead  red  color  when  they  are  to  be  ap- 
plied. The  glass  rods,  heated  in  a  like  manner,  though  somewhat  more 
convenient,  become  very  quickly  cool. 

Dr.  J.  J.  Putnam,  of  Boston,  exhibited  at  a  meeting  of  the  American 
Neurological  Association  the  first  gas  cautery  which  was  seen  in  this 
country.  In  some  respects  it  was  imperfect.  It  produced  a  noise  which 
was  harrowing  to  the  patient,  and  it  was  expensive  and  cumbersome. 
The  apparatus  consists  of  two  pipes  (one  within  the  other),  which  convey 
air  or  oxygen  and  illuminating  gas  to  a  common  burner.  These  tubes  are 
connected  with  stopcocks  (Fig.  8,  A,  2,  2),  which  enable  the  operator  to 
control  the  size  of  the  flame.  A  handle  (1)  covered  at  one  end  by  a 
shield,  completes  the  body  of  the  instrument.  At  the  end  of  the  burner 
is  a  dome  of  platinum,  which  is  fastened  to  the  end  of  the  burner  by  a 
ring  and  clump  (li<  4),  so  that,  by  a  simple  movement,  the  dome  can  be 
removed  and  replaced  by  another.  About  the  lower  edge  of  tfe  pla- 
tinum, is  a  small  collar  of  wire  gauze,  expanded  at  its  lower  end,  which 
prevents  the  escape  of  any  return  flame  (B). 

From  the  two  stopcocks  pass  rubber  tubes,  one  to  the  gas-burner,  the 
other  to  a  T  of  brass  pipe,  the  middle  branch  of  which  extends  into  a 
large  spinal  ice-bag  (A,  3).  This  is  covered  by  a  strong  net.  To  the 
other  branch  a  rubber  tube  is  attached.  This  tube  terminates  in  an  ordi- 
nary rubber  atomizer-bulb. 


CAUTERIES. 


33 


At  the  T-piece  is  a  small  hook  (A,  4),  by  which  the  ice-bag  or  air- 
reservoir  can  be  attached  to  the  button-hole  of  the  operator. 

Fig.  8 


The  Author's  Gas  Cautery. 

The  advantages  I  claim  for  the  modification  of  the  instrument  I  have 
described  are  the  following  : — 

1.  The  adoption  of  a  jet  which  prevents  all  hissing  or  noise,  and  still 
produces  a  very  powerful  blast. 

2.  The  apron  of  wire  gauze,  which  prevents  the  return  of  flame,  thus 
obviating  the  danger  of  burning  parts  that  we  do  not  wish  to  affect. 

3.  The  large  bag,  which  acts  as  a  reservoir,  so  that  the  operator  need 
not  use  the  rubber  bulb  nor  watch  the  burner  after  it  is  filled. 

4.  The  hook,  which  enables  him  to  suspend  the   bag  and  tubing  from 
his  person,  thus  removing  all  drag. 

The  general  advantages  of  this  form  of  cautery  are  important.  A  uni- 
form heat  may  be  kept  up  for  hours  with  very  little  exertion.  The  fur- 
nace, which  is  not  only  inconvenient,  dirty,  and  alarming  to  timid  people, 
but  is  a  slow  method,  is  done  away  with.  In  less  than  a  minute  the 
platinum  dome  can  be  heated  to  whiteness. 
3 


34  INTRODUCTION. 

The  cauteries  of  Pacquelin  and  Guerard,  of  Paris,  are  both  good.  In 
them  the  \n\tor  of  benzine  (which  should  be  very  pure)  is  forced  with  air 
upon  a  piece  of  hot  platinum.  These  are  excellent  substitutes  for  tin- 
cautery  I  have  just  described,  in  the  country  where  there  is  no  gas. 

Dr.  Hammond  has  recommended  that  the  spinal  ether  spray  be  used  to 
deaden  pain ;  but  not  only  is  there  danger  of  an  explosion  when  this  pro- 
cedure is  tried,  but  it  seems  to  me  that  the  very  object  of  the  operation, 
revulsion,  is  not  accomplished,  as  the  peripheral  filaments  are  of  necessity 
benumbed. 


ACUTE    PACHYMENINGITIS.  35 


CHAPTER   I. 

DISEASES  OF  THE  CEREBRAL  MEXINGES. 

ALL  of  the  investing  membranes  of  the  brain  may  be  the  seat  of  inflam- 
matory action,  but  it  is  almost  impossible  in  certain  instances  to  make 
distinctions  between  inflammation  of  the  arachnoid  and  pia  mater,  though 
this  lias  been  attempted  by  Parent-Duchatelet,  Lallemand,  and  others.  We 
will,  therefore,  have  to  content  ourselves  with  a  division  founded  upon  the 
duration,  intensity,  and  coexisting  diseases  of  the  general  system,  and 
limit  our  regional  diagnoses  to  forms  which  may  be  called  meningitis  of 
the  convexity  and  meningitis  of  the  base. 

In  respect  to  certain  circumstances  which  modify  the  appearance  of  the 
disease  we  may  divide  these  neuroses  as  follows  : — 

...  (  Acute, 

Cerebral  pachymemngitis,  \ 

,1   n  A.    '     »,»     j  N  •<    Chronic, 

(Inflammation  or  the  dura  mater), 

(^  Chronic,  with  lutmatoma. 

f  Basilar, 

Acute  cerebral  meningitis,  ^  Of  the  convexity, 

(.  Granular. 
Chronic  cerebral  meningitis. 


PACHYMENINGITIS  (INFLAMMATION  OF  THE  DURA). 

Two  forms  of  pachymeningitis  are  to  be  met  with,  one  of  which  is  acute 
and  is  the  direct  result  of  injury  or  disease  of  the  cranial  bones,  and  is 
generally  fatal  in  a  short  time ;  and  the  other,  of  a  chronic  nature,  which 
may  either  remain  after  injury,  or  arise  from  some  intracranial  cause,  or 
perhaps  be  the  result  of  general  disease,  or  old  age. 

ACUTE  PACHYMEXIXGITIS. 

Symptoms After  the  traumatism,  or  when  the  external  disease  has 

invaded  the  intracranial  cavity,  the  first  symptom  is  usually  severe  and 
localized  pain,  which  finally  extends  with  the  inflammation,  and  becomes 
diffused  over  the  entire  head. 

Rigors,  alternating  with  elevation  of  temperature,  which  may  sometimes 
attain  105°  or  10G°  F.,  occasionally  spasms  of  the  arms  or  legs,  are  ordi- 
nary symptoms  ;  and  if  the  condition  be  a  very  acute  one,  there  may  be 
general  convulsions,  or  perhaps  a  partial  paralysis,  which  is  unilateral. 

Delirium  usually  supervenes  in  from  three  days  to  a  week,  and  coma 


36  DISEASES    OF    THE    CEREBRAL    MENINGES. 

ends  the  disease,  should  an  effusion  of  blood  take  place,  and  this  is  a  com- 
mon termination. 

The  pulse  during  the  first  two  or  three  days  varies  from  60°  to  70°, 
while  towards  the  end  it  becomes  much  more  frequent  and  very  full. 
During  the  invasion,  and  after  the  disease  is  fully  established,  especially 
if  the  inflammation  extends  to  the  base,  the  head  may  be  drawn  backwards 
and  downwards. 

Ramskill1  has  called  attention  to  the  hyper-sensitiveness  of  the  cornea, 
and  I  have  been  often  impressed  by  another  symptom,  viz.,  the  redness  of 
the  conjunctiva  and  the  constant  tendency  to  lachrymation.  Vomiting 
very  commonly  takes  place,  and  is  always  quite  a  suggestive  symptom  of 
meningeal  trouble.  When  the  disease  follows  otitis  its  onset  is  not  so  sud- 
den us  when  it  is  the  result  of  injury,  but  a  train  of  symptoms  of  gradual 
appearance  marks  the  extension  of  the  morbid  process  step  by  step, 
though  in  some  instances  rigor  with  sudden  coma  may  be  the  first  indica- 
tion of  mischief.  This  is  in  most  cases  the  purulent  form.  Cases  of  the 
idiopathic  variety  of  pachymeningitis  are  quite  rare,  although  several  have 
been  reported  by  Abercrombie  and  other  older  writers.  One  case  related 
by  the  former  authority  may  be  worth  mentioning.  This  writer  also  gives 
six  others  which  originated  from  middle  ear  disease  or  abscesses  in  other 
bony  cavities.  These  latter  cases  are  not  uncommon,  if  we  may  accept 
the  experience  of  aurists  and  surgeons.  AbercrombieV  patient,  in  whom 
the  disease  was  idiopathic,  died  in  fifteen  days.  The  first  indication  was 
severe  pain  in  the  left  temple,  which  continued  for  two  weeks,  when  a 
"  swelling"  appeared  beneath  the  left  upper  eyelid.  Four  days  before  her 
death  violent  convulsions  took  place,  which  were  preceded  by  slight 
rigors.  The  swelling  was  punctured,  and  a  considerable  quantity  of  pus 
escaped.  A  probe  passed  into  the  opening  came  in  contact  with  bone,  and 
could  be  inserted  for  some  distance,  the  end  being  in  contact  with  the  roof  of 
the  orbit.  During  previous  days  her  condition  had  varied  to  a  great  degree, 
and  at  times  she  seemed  to  be  very  comfortable.  On  the  day  before  her 
death  she  complained  of  vertical  headache,  became  semi-comatose,  and  died 
in  this  state.  Extensive  discoloration,  thickening,  and  other  changes  in 
the  dura  mater  were  found  with  adventitious  membrane  and  pus. 

Fizeau8  mentions  a  case  which  closely  resembles  this  one,  and  another 
quoted  by  Abercrombie,  and  seen  by  Prathernon,  was  also  of  idiopathic 
origin.  Abercrombie'a  other  cases  present  common  symptoms  which  were 
traced  to  assignable  causes.  Dr.  Clark*  has  presented  five  cases  of  the 
acute  form,  due  to  otitis.  Dr.  Banduy8  another  which  followed  scarlet 
fever,  and  many  of  the  same  kind  may  be  found  mentioned  by  other 
authorities. 

1  Russell  Reynolds'  System  of  Medicine,  vol.  ii.  page  325. 

2  Abercrombie  on  the  Brain,  page  21. 

3  Journal  de  M6decine,  torn,  ii.,  New  Series,  page  523. 

4  Transactions  New  York  Pathological  Society,  1876. 

5  St.  Louis  Clinical  Record,  March,  1876. 


CHRONIC    PACHYMEX1NGITIS.  37 

CHROXIC  PA.CHYMEXINGITIS. 

A  far  more  interesting  class  of  cases  are  those  which  have  lasted  for 
some  time,  have  invaded  the  underlying  membranes,  ending  in  involve- 
ment of  the  cortex  cerebri.  The  following  is  a  fair  example  : — 

Symptoms — John  McM.,  age  30,  of  temperate  habits.  The  patient 
was  a  young  man  of  the  laboring  class,  and  was  employed  in  a  machine- 
shop  at  the  time  of  the  accident.  Three  years  ago,  while  turning  a  piece 
of  metal,  it  caught  upon  the  end  of  his  turning  tool  and  flew  out  of  the 
lathe  (which  was  driven  by  steam-power),  striking  his  head,  and  cutting  a 
scalp  wound  over  the  upper  part  of  the  right  parietal  bone.  He  fell  un- 
conscious, and  was  carried  to  his  home,  remaining  in  the  same  state  for 
about  eight  hours.  After  this  he  recovered  slowly,  was  delirious,  and  evi- 
dently had  had  convulsions.  From  this  period  to  the  time  when  I  saw  him 
his  history  was  not  very  clear,  but  he  had  had  convulsive  paroxysms  from 
time  to  time,  and  severe  headache,  which  he  complained  of  when  he  came 
for  advice.  This  pain  was  limited  to  the  right  side  of  the  head,  and  prin- 
cipally centered  at  the  injured  spot.  His  face  was  quite  puffed  and 
swollen,  and  his  eyes  were  red  and  watery.  Pressure  upon  the  cicatrix 
caused  intense  pain.  His  right  pupil  was  slightly  enlarged,  and  he  com- 
plained that  his  vision  was  imperfect.  Sleep  was  disturbed  by  the  pain 
which  would  often  occur  in  paroxysms  of  a  very  intense  character.  He 
complained  that  his  left  arm  felt  stiff,  and  that  his  fingers  were  cold,  but 
I  was  unable  to  find  any  loss  of  power.  He  continued  in  this  state  for  a 
year  or  more,  and  when  I  next  saw  him  his  speech  had  become  slow  and 
hesitating,  and  his  face  wore  rather  a  silly  expression.  He  then  com- 
plained of  some  feebleness  of  the  left  arm  and  leg.  The  headache  had  not 
abated,  and  the  convulsions  had  been  much  more  frequent.  His  friend 
who  came  with  him  stated  that  his  mind  had  greatly  changed,  that  his  be- 
havior was  eccentric,  and  that  he  had  had  delusions  of  various  kinds.  I 
subsequently  lost  sight  of  him.  In  some  features  this  case  resembles  one 
of  softening.  This  form  of  chronic  pachymeningitis  is  much  more  obscure 
when  it  is  connected  with  syphilis.  There  is  not  only  a  great  dispropor- 
tion between  the  severity  of  the  symptoms  and  the  extent  of  the  morbid 
process,  but  symptoms  of  great  variety  may  be  evinced  as  expressions  of 
pachymeningitis  of  syphilitic  origin.1  Lagneau  fils2  reports  a  case  in  which 
this  inconsistency  was  shown.  The  only  symptom  was  headache,  which 
was  most  violent  at  night.  Post-mortem  examination  revealed  pachy- 
meningitis over  the  anterior  lobes  of  the  cerebrum,  with  bony  plates  and 
some  sclerosis  of  the  brain-substance.  There  was,  in  addition,  extensive 
perforation  of  the  ethmoid  bone.  Instances  are  related  by  Gama  where 
the  patients  had  died  conscious,  and  their  meninges  Avere  found  to  be  de- 
cidedly affected.  Keyes,3  in  a  most  complete  and  exhaustive  memoir,  pre- 

1  Trans.  X.  Y.  Path.  Soc.,  vol.  i.  p.  13. 

2  Observation  3,  Lagneau,  Maladies  syphilitiques  du  Systeme  nerveux.    Paris, 
1860. 

3  Syphilis  of  the  Nervous  System.     New  York,  1870. 


38  DISEASES    OF    THE    CEREBRAL    MENINGES. 

sent.*  a  number  of  cases  of  hemiplegia  which  were  the  ultimate  result  of 
the  meningeal  inflammation,  and  calls  attention  to  the  pain  which  pre- 
cedes the  hemiplegia,  and  which  is  always  produced  when  pressure  is  made 
upon  the  cranium.  A  feature  of  the  hemiplegia  is  the  absence  of  any  loss 
of  consciousness. 

A  form  of  syphilitic  pachymeningitis  may  follow  external  syphilitic  dis- 
ease of  the  cranial  bones.  I  may  illustrate  the  features  of  such  an  attack 
by  the  following  case,  reported  by  Dr.  Jas.  R.  Wood : — 

Marie  C.,  aged  20,  was  admitted  to  Bellevue  Hospital,  Jan.  7th,  on  ac- 
count of  an  eruption  of  two  weeks'  duration,  which  had  steadily  progress  ,1 
from  a  few  points  until  it  had  become  general,  being  most  profuse  on  tin- 
face,  neck,  arms,  and  scalp. 

The  eruption  presented  a  distinct  coppery  hue,  and  was  of  two  varieties. 
There  were  three  rupitic  phlegma  on  the  head,  each  of  which  contained  a 
little  pus,  and  three  or  four  on  the  shoulders  and  back  of  the  same  cha- 
racter. The  rest  were  tubercular. 

She  stated  that,  though  often  exposed,  she  had  never  suffered  from  pri- 
mary syphilis,  but  that  there  was  a  sore  on  her  thigh,  near  the  vulva. 
which  appeared  two  weeks  before  the  eruption. 

On  examination,  a  simple  chancre  was  found  at  the  point  complained 
of;  there  was  also  a  chancre  of  limited  extent  in  the  vagina.  Soon  after 
admission  she  was  observed  to  have  a  shuffling  gait,  and  when  questioned 
about  it  stated  that  her  right  arm  and  leg  "  seemed  to  be  getting  weak." 
The  treatment  consisted  in  the  use  of  the  corrosive  chloride  of  mercury  in 
Huxham's  tincture  of  bark,  combined  with  generous  diet. 

The  eruption  on  the  scalp  was  left  undisturbed.  The  quantity  of  pus 
contained  in  each  point  was  quite  small,  and  it  was  deemed  best  to  let 
them  alone.  One  of  them  situated  over  the  parietal  bone  of  the  left  side 
was  something  larger  than  its  fellows ;  none  of  them,  however,  increased 
in  sixe  materially. 

There  was  very  little  improvement  in  the  eruption,  but  the  hemiplegia 
steadily  increased. 

Her  appetite  became  poor,  she  began  to  have  vomiting,  and  exhibited 
n  cachectic  appearance.  The  bichloride  was  necessarily  discontinued,  and 
mercurial  vaporization  substituted. 

The  hemiplegia  became  more  complete,  and  her  mind  began  to  be  ob- 
scured. The  stupidity  gradually  deepened  into  profound  coma,  in  which 
condition  she  died  on  the  30th. 

Autopsy — There  was  a  denudation  of  the  parietal  bone  of  the  left  side 
of  the  periosteum,  at  a  point  corresponding  with  the  rupitic  spot  above 
spoken  of. 

On  removing  the  calvarium,  the  dura  mater  was  found  inflamed  and 
firmly  adherent  to  the  skull,  just  beneath  the  denuded  spot  on  the  panfetal 
bone  and  the  eruption. 

A  small  opening  was  found  communicating  between  them,  perforating 
the  cranial  walls,  and  looking  very  much  like  a  worm -hole. 

The  brain  at  a  point  corresponding  with  the  inflamed  dura  mater  pre- 
sented a  greenish  appearance. 

There  was  also  an  evident  fulness  and  fluctuation.  On  making  an  in- 
cision an  abscess  was  discovered  which  contained  about  ^iij  of  pus.  The 
other  organs  were  healthy. 


CHRONIC    PACHYMENINGITIS. 


39 


As  a  result  of  continued  congestion  we  may  have  a  form  of  pachy- 
meningitis  such  as  follows  chronic  mania.  I  have  seen  this  change  repeat- 
edly as  a  secondary  condition,  but  it  must  be  confessed  that  the  other 
iiH'ninges  were  as  well  affected. 

Causes — They  may  be  briefly  enumerated  as  external  injury,  otitis, 
syphilis,  alcoholism,  and  various  acute  diseases,  among  them  rheumatism. 

Morbid  Anatomy  and  Pathology — In  the  majority  of  cases  the 
inflammation  is  transmitted  to  one  or  more  of  the  important  sinuses.  The 
most  favorable  points  for  the  extension  of  disease  of  the  temporal  bone  are 
the  narrow  space  between  the  mastoid  cells  of  this  bone  and  the  transverse 
sinus,  and  that  between  the  cavity  of  the  tympanum  and  the  jugular  fossa ; 
and  the  proximity  of  the  auditory  meatus  to  the  petrosal  sinus,  and  the 
different  canals  which  contain  the  nerves,  to  adjacent  intra-cranial  parts. 
The  bony  walls  between  these  locations  are  of  a  perforated  and  lamellar 
character,  and  when  attacked  by  caries  are  very  apt  to  be  destroyed. 

If  the  disease  be  of  a  syphilitic  nature  there  is  generally  a  gummatous 
deposit  scattered  through  the  tissues,  and  the  under  surface  of  the  dura 
mater  is  often  covered  by  a  syphilitic  exudation  which  can  rarely  be  mis- 
taken. If  the  disease  be  the  result  of  a  traumatism,  the  membrane  is  seen 
to  be  thickened,  opalescent,  and  congested.  In  old  cases  it  is  found  to  be 
closely  adherent  to  the  cranial  bones,  or  it  may  contain  long  plates. 


Osteoma  of  Dura  Mater  (Lancereaux). — a.  Bony  Plate.    6.  Perforation,    c.  Falx.    d.  Dura 
Mater,     e.  Parietal  Bone.    /.  Scalp. 

In  this  form  of  inflammation  the  morbid  changes  may  be  seen  best  at 
the  convexity. 

Prognosis The  outlook  is  invariably  bad,  for  in  one  variety  the 

patient  is  carried  off  in  a  few  days,  or,  should  the  disease  become  chronic, 
its  progressive  nature  must  lead  us  to  expect  an  ultimate  implication  of 
other  parts,  and  cortical  softening  or  sclerosis  and  atrophy  are  probable 
terminations. 


40  DISEASES    OF    THE    CEREBRAL    MENINGES. 

Treatment Treatment  should  be  directed  in  the  beginning  to  the 

cause,  and  if  there  be  otitis,  a  free  escape  of  pus  should  be  provided  for, 
and  counter-irritants,  topical  applications,  and  leeches  should  be  em- 
ployed. If  the  pachymeningitis  be  attended  by  much  pain,  cold  to  the 
liead  and  free  administration  of  the  bromides  will  be  of  service.  The 
leeches  may  be  applied  to  the  tragus  of  the  ear,  or  to  the  mucous  mem- 
brane of  the  nostril. 

CHRONIC  PACHYMENIXGITIS  WITH  H^EMATOMA. 

It  has  been  the  custom,  among  certain  writers  lately,  to  speak  of  luema- 
toma  as  an  inevitable  result  of  pachymeningitis.  This,  I  think,  is  a  mis- 
take, for  the  production  of  blood-cysts  is  not  the  invariable  rul*».  If, 
however,  the  thickening  of  the  dura  mater  is  excessive,  there  may  be  a 
gradual  destructive  process,  which  will  be  described  when  we  come  to 
speak  of  the  morbid  anatomy  and  pathology  of  the  affection. 

The  disease  may  begin  as  I  have  already  described,  and  may  advance 
to  a  certain  point  before  the  grave  symptoms  which  indicate  rupture  and 
consequent  meningeal  hemorrhage  are  expressed.  These  may  vary  in 
intensity  in  proportion  to  the  extent  of  the  effusion,  which  may  be  even 
so  great  as  to  produce  sudden  death,  but  such  an  early  result  is  excep- 
tional. The  course  of  the  disease  is  generally  more  gradual,  and  there  is 
at  first  an  initial  hemorrhage  of  slight  extent,  which  is  followed  in  a  great 
number  of  cases  by  two  or  three  others.  In  some  respects  this  effusion  re- 
sembles cerebral  hemorrhage  in  the  production  of  acute  symptoms,  but 
they  are  nearly  always  less  profound ;  and  it  is  not  so  frequently  followed 
by  complete  paralysis. 

Symptoms — The  early  symptoms  of  pachymeningitis  which  I  have 
enumerated  are  those  preceding  the  immediate  evidences  of  the  effusion. 
They  may  be  reinforced  by  loss  of  memory  and  stupidity,  and  after  a  few 
months  there  may  be  a  transitory  loss  of  consciousness  and  incomplete 
hemiplegia  which  is  characterized  by  much  hyperaesthesia. 

The  phenomena  of  the  attack  are  thus  described  by  Huguenin  :l  "  Se- 
vere headache  just  before  the  attack ;  after  loss  of  consciousness  has 
occurred,  contracted  pupils,  not  reacting ;  in  a  few  cases,  paralysis  of  the 
facial  nerve,  on  the  side  opposite  to  that  of  the  haematoma ;  sometimes 
hemiplegia.  These  latter  symptoms  only  occur  in  one-sided  hemorrhages. 
A  marked  change  in  the  color  of  the  face  is  another  of  the  symptoms  re- 
j>orted.  At  the  commencement  of  the  attack,  which  is  usually  suddeo; 
the  face  becomes  flushed  ;  the  pulse  is  full  and  rapid,  but  soon  grows  small 
and  irregular,  and  pallor  succeeds  the  flushing.  In  some  cases  the  pulse 
is  slow ;  in  others  there  is  an  increase  in  rapidity,  continuing  up  to  the 
time  of  death.  Contractures  of  the  extremities,  and  slight  transitory 
twitchings,  were  present  in  a  few  cases." 

1  Zicmssen,  Cyclopedia  of  the  Pract.  of  Mod.,  translation,  vol.  xii.  page  409. 


CHRONIC    PACHYMENINGTTIS.  41 

Instead  of  hemiplegia  there  may  be  one-sided  convulsions,  but  these 
depend  very  much  on  the  degree  of  pressure  exerted  upon  the  cortex- 
cerebri.  The  condition,  strange  to  say,  is  sometimes  arrested  after  an 
indefinite  period,  and  there  is  a  return  to  the  normal  state,  but  traumatic 
htematoma  is  usually  fatal. 

Schuhberg1  assents  to  the  view  held  by  Herschl,  Virchow,  and  Cruveil- 
hier,  that  ha?matoma  is  always  the  result  of  fibrinous  inflammation,  and 
believes  that  the  prognosis  is  grave.  In  this  paper  he  considers  the  dura- 
tion of  a  fatal  case  to  be  about  one  month. 

Causes — Ha?niatoma  is  a  disease  of  adult  life,  and  twenty-two  per 
cent,  of  the  cases  collected  by  Huguenin  were  between  the  seventieth  and 
eightieth  years,  and  Durand-Fardel  found  that  77.4  per  cent,  of  all  cases 
were  men,  and  22.6  per  cent,  were  women.  As  causes  may  be  mentioned 
various  cachectic  and  other  diseases,  among  them  Bright's  disease,  scurvy, 
syphilis,  typhus  fever,  rheumatism,  smallpox  and  scarlatina,  alcoholism  and 
sunstroke,  or  any  condition  which  is  conducive  to  continued  hyperzemia  of 
the  dura  mater. 

Morbid  Anatomy  and  Pathology The  process  involved  in  the 

production  of  hrematoma  is  an  exceedingly  complicated  one,  consisting 
in  the  production  of  new  vessels  and  new  layers  of  fibrine  due  to  the  ex- 
travasation of  blood.  The  first  layer  of  this  new  tissue-formation  takes 
place  in  contact  with  the  arachnoid,  and  ultimately  others  form  and  be- 
come organized.  The  formation  of  the  blood-cyst  is  due  to  the  rupture 
of  one  of  the  new  vessels,  and  the  extravasation  becomes  surrounded  by  a 
layer  of  tissue  which  may  be  so  firm  as  to  preserve  the  cyst  contents  un- 
changed. This  is  particularly  the  case  in  the  smaller  cysts.  The  skull  is 
sometimes  found  to  be  thin  as  seen  by  Hyrtl,2  but  this  is  not  common,  and 
some  writers,  among  them  Textor3  and  Rokitansky,*  consider  that  the 
reverse  is  to  be  seen  in  a  greater  number  of  cases.  I  may  briefly  enume- 
rate the  post-mortem  appearances  as  follows  :  Beneath  the  dura  mater  may 
be  found  a  layer  of  coagulum  which  contains  fibrinous  shreds  binding  it  to 
the  membrane  itself.  If  the  case  be  of  long  duration  several  layers  of 
false  membrane  containing  bloodvessels  are  to  be  found  attached  to  the 
dura,  and  the  late  formations  may  be  distinguished  from  those  of  early 
origin.  Between  these  layers  it  is  not  unusual  to  find  the  results  of  inter- 
stitial hemorrhages  which  exist  as  blood-clots  in  different  styles  of  organi- 
zation. The  thickening  of  the  dura  mater  is  thus  described  by  Fox  : 
"  In  the  non-purulent  form  of  the  new  formation,  the  result  of  inflamma- 
tion becomes  very  quickly  the  seat  of  vessels  and  is  composed  of  several 
layers ;  those  nearest  the  dura  mater  being  composed  of  compact  lustrous 
connective  tissue  fibres  almost  as  dense  as  the  dura  mater  itself,  whilst  the 
layer  further  removed  from  the  dura  mater  is  rich  in  cells  with  small 

1  Schmidt's  Jahresbericht,  vol.  104,  pp.  164,  165. 

2  Hyrtl,  see  Ziemssen's  Encyl.,  vol.  xii.  Am.  Tran.,  Art.  "  Meningitis." 

3  Textor,  AVlirzburg  Yerhandlung,  vii.  1857. 
*  Rokitansky,  quoted  by  Huguenin. 


42  DISEASES    OF    THE    CEREBRAL    MENINGES. 

iwrrow  vessels,  and  the  layer  nearest  the  arachnoid,  often  firmly  uniting 
the  arachnoid  to  the  dura  mater,  is  remarkable  for  very  large  capilla- 
ries." 

The  size  of  the  lurmatoma  may  vary  from  that  of  a  small  bean  to  that 
of  an  orange,  and  in  one  case,  the  autopsy  of  which  was  made  by  Dr. 
Huber  of  the  Colored  Home,  the  blood-cyst  covered  one  entire  side  of  the 
brain,  and  was  fully  an  inch  in  depth.  The  patient  was  under  the  care  of 
Dr.  "Whitall,  who  kindly  contributes  the  following  notes : — 

P.  B.,  00,  widower,  X.  Y. ;  mulatto;  father,  mother,  and  one  brother 
died  of  phthisis.  The  patient  has  been  intemperate,  but  now  drinks  only 
in  moderation.  He  denies  venereal  disease;  twenty-five  years  ago  he 
had  smallpox,  and  has  since  had  intermittent  fever  and  cholera.  His 
trouble  dated  from  an  injury  seven  years  ago.  He  was  thrown  from  a 
hay-truck  to  the  ground,  falling  upon  his  head,  and  causing  blood  to  flow 
from  his  left  ear;  but  he  was  able  to  walk  to  his  home,  one  mile  distant. 
He  seems  to  have  received  no  very  serious  injury,  if  we  may  judge  from 
the  immediate  symptoms.  Since  the  fall  he  has  been  troubled  with  head- 
ache oft'  and  on,  increased  by  approaching  a  fire.  He  cannot  appreciate 
the  ticking  of  a  watch  pressed  to  his  left  ear.  About  a  fortnight  ago  he 
had  a  chill,  fever,  and  cough,  some  pain  in  back,  with  soreness  around 
the  whole  gluteal  region.  Urination  was  slow,  disturbed,  and  at  one  time 
he  was  unable  to  pass  water;  at  another  it  would  be  too  free;  has  been 
growing  weaker  since. 

June  15,  1874.  On  admission  patient  was  confined  to  bed;  owing  to 
apparent  weakness  in  lumbar  region  he  was  unable  to  stand.  In  a  few 
days  he  began  to  improve  under  the  administration  of  iodide  of  potash. 
"Walks  with  a  staggering  gait,  and  cannot  follow  a  straight  line.  On 
closure  of  eyes  does  not  have  a  tendency  to  fall.  Heavy  expression  of 
countenance.  No  diminution  in  acuteness  of  sensibility  can  be  discovered 
over  any  portion  of  the  body.  Had  incontinence  of  urine  on  admission; 
is  not  so  troubled  at  present  time.  Can  walk  about  the  ward ;  at  times 
can  dress  without  assistance.  To-day  complains  of  frontal  headache; 
sleeps  very  soundly,  with  stertorous  breathing.  Appetite  good ;  bowels 
constipated. 

24M.  Staggering  gait,  and  inability  to  walk  in  a  straight  line,  still  pre- 
sent. If  he  closes  his  eyes  while  standing,  there  is  a  tendency  (which  by 
an  effort  he  can  overcome)  to  fall  backward.  Complains  of  pain  on  right 
side  of  head  and  face;  sleeps  most  of  the  day  in  a  chair;  at  night  snores 
loudly.  Bowels  constipated.  Nocturnal  incontinence  of  urine  exists. 

Feb.  fi,  187").  To-day,  while  patient  was  sitting  in  a  chair,  he  had  a 
convulsion,  and  then  becamo  comatose.  Urine  albuminous.  Ordered  ol. 
tiglii  n\\\,  after  the  action  of  which  he  appeared  much  better. 

15th.  Very  little  change  in  patient's  general  condition  since  above 
note.  Is  still  apathetic,  and  complains  of  pain  in  head,  on  right 
side  especially.  There  is  still  right  facial  paralysis,  with  somewhat  di- 
minished sensibility  in  this  region.  The  tongue  deviates,  if  any,  to  the 
right.  Pupils  normal  in  size  and  reaction.  No  notable  change  in  hear- 
ing. No  loss  of  motion,  though  the  right  arm  and  leg  are  weaker  than 
the  left.  The  lower  limbs  (left  more  readily  than  right)  can  be  drawn 
upwards,  and  extended  with  little  trouble.  lie  is  unable  to  walk  or  stand 
without  being  supported,  as  the  right  leg  gives  way ;  complains  of  con- 


CHRONIC    PACHYMENINGITIS.  43 

sidorable  pain  in  the  upper  portion  of  the  limb.  Has  occasional  involun- 
tary passages  of  urine  and  feces ;  as  a  general  thing,  however,  the  bowels 
are  confined  ;  urine  evacuated  with  considerable  force. 

March  19.  Appears  to  be  losing  strength  very  rapidly.  Will  not  an- 
swer when  spoken  to.  Temp.  99£°. 

21  st.     Died  about  9  P.M.  comatose. 

Autopsy,  36  hours  post-mortem — Rigor  mortis  marked.  Body  slightly 
emaciated. 

The  dura  mater  was  found  very  firmly  adherent  to  the  calvarium  to  the 
right  of  the  longitudinal  sinus,  and  over  a  considerable  portion  of  the  con- 
vexity. After  removing  the  dura  mater,  the  pia  mater  on  the  left  side 
was  discovered  to  be  unusually  dry  and  somewhat  congested,  with  here  and 
there  slight  patches  of  lymph.  The  convolutions  throughout  this  hemi- 
sphere were  greatly  flattened,  and  the  sulci  nearly  obliterated.  In  the 
right  cranial  cavity  a  large  haematoma  existed.  The  tumor  pear-shaped, 
with  larger  extremity  anteriorly,  extended  from  the  anterior  portion  of 
the  second  frontal  convolution  to  the  posterior  portion  of  the  second  tem- 
poral, and  from  within  an  inch  of  longitudinal  fissure  to  junction  of  lateral 
portion  with  base  of  skull. 

The  right  hemisphere  was  correspondingly  compressed  downwards, 
backwards,  and  to  the  left.  The  depression  corresponded  to  the  shape  of 
the  tumor,  and  was  so  situated  that  the  greatest  amount  of  pressure  came 
upon  the  left  lateral  ventricle.  The  dimensions  of  this  growth  were  as 
follows :  6^  inches  antero-posteriorly ;  4  inches  vertically  in  greatest  diam- 
eter ;  and  about  2  inches  in  thickness. 

In  addition  to  the  luvmatoma,  a  serous  cyst  (about  the  size  of  a  hickory- 
nut),  evidently  originating  from  an  old  hemorrhage  in  the  subjacent  brain 
structure,  the  cicatrice  of  which  still  remains,  was  seen  beneath  the  an- 
terior lobe.  Back  of  this  another  cyst,  the  walls  of  which  were  chiefly 
composed  of  softened  brain  tissue,  was  discovered,  which,  upon  closer 
investigation,  was  ascertained  to  be  continuous  with  the  right  lateral  ven- 
tricle through  the  middle  cornua.  The  right  ventricle  was  greatly  dis- 
tended by  serum,  wrhile  comparatively  little  could  be  detected  in  the  left. 

In  the  left  ophthalmic  artery  a  long,  slender  clot,  partly  dark  and 
partly  translucent  and  yellowish,  existed.  No  thrombi  were  noticed  in 
the  slightly  atheromatous  arteries  at  the  base  of  the  brain. 

No  connection  existed  between  the  pia  mater  and  the  hoematoma ;  the 
relations  between  it  and  the  dura  mater  were  so  intimate  as  to  require 
dissection  before  a  separation  was  possible. 

The  petrous  portion  of  the  right  temporal  bone  was  considerably  larger 
than  the  left,  and,  upon  section,  proved  to  be  much  more  porous.  No 
other  abnormalities  were  present;  no  evidence  of  fracture  at  the  base. 

The  way  in  which  the  tumor,  though  situated  on  the  right  side  of  the 
brain,  pressed  upon  the  left  ventricle,  explained  the  symptoms  which, 
during  life,  pointed  to  an  involvement  of  the  left  side ;  and  also  offered  an 
explanation  as  to  the  manner  in  which  the  fluid  was  forced  through  the 
middle  cornua  of  the  right  ventricle. 

Heart Very  flabby;    cavities  dilated,  and  filled  with    dark    coagula. 

Aortic  valves  were  slightly  thickened,  and  the  artery  was  atheromatous. 
Mitral  valves  thickened. 

Lungs The  right  was  firmly  bound  to  chest;  very  soft  and  congested. 

The  surface  was  studded  with  pigment. 


44  DISEASES    OF    THE    CEREBRAL    MENINGES. 

The  left  had  also  become  adherent  to  parietes,  and,  at  the  apex,  a  few 
softened,  cheesy  points  were  discovered. 

Spleen — Enlarged  and  congested. 

Liver. — Normal. 

Kidneys Cortex  somewhat  thicker  than  usual;  both  organs  \\. TV 

waxy. 

Weight  of  the  organs. — Heart,  10  oz.  ;  spleen,  7  ox. ;  liver,  55  oz. ; 
right  lung,  29  oz. ;  left  lung,  18  oz. ;  right  kidney,  6  oz. ;  left  kidney,  5  oz. 

Prognosis The  existence  of  a  blood  tumor  of  this  kind  is  not 

always  a  serious  matter.  Even  after  two  or  three  extravasations  have 
occurred,  a  retrogressive  course  takes  place ;  but  this  is  rare.  Griesinger1 
reports  a  case  in  which  partial  recovery  has  taken  place;  and  in  1870  the 
patient  was  still  alive,  and  presented  slight  evidences  of  his  former  serious 
trouble.  This  termination  of  the  disease  is  exceptional,  however. 

Treatment What  has  been  said  in  regard  to  the  management  of 

uncomplicated  pachymeningitis  is  applicable  in  this  disease ;  and,  in  addi- 
tion, venesection  has  been  advocated  by  more  than  one  authority.  It  should 
be  employed  during  the  comatose  stage  which  marks  the  occurrence  of  an 
effusion,  and  at  the  same  time  a  drastic  cathartic  will  be  found  to  be  of 
excellent  service.  High  living  and  excessive  use  of  tobacco  and  alcohol 
are  to  be  interdicted,  and  iodide  of  potassium  may  be  given  with  the  idea 
of  producing  absorption  of  the  new  growth. 


ACUTE  CEREBRAL  MENINGITIS. 

The  term  meningitis  has  been  applied,  clinically  speaking,  to  that  form 
of  inflammation  which  involves  chiefly  the  arachnoid  and  pia  mater,  and  in 
its  acute  form  may  be  expressed  by  the  following  grave  and  alarming 
symptoms  : — 

Symptoms — These  may  be  divided  in  regard  to  their  appearance 
into  three  stages:  1st.  The  stage  of  excitement  or  irritation;  2.  The 
stage  of  delirium  ;  3d.  The  stage  of  stupor. 

An  hypothetical  case  may  be  presented.  The  patient  complains  of  a 
slight  headache,  which  increases  towards  the  end  of  the  first  twenty-four 
hours.  It  may  not  be  attended  by  much  annoyance,  and  he  is  usually  able 
to  attend  to  his  daily  duties.  But  during  the  succeeding  six  or  eight 
hours  it  may  become  greatly  aggravated,  and  is  attended  by  restlessness, 
flushing  of  the  cheeks,  throbbing  of  the  temporal  vessels,  and  general  dis- 
comfort. After  a  few  hours  there  may  be  slight  rigors  or  a  severe  chill, 
which  is  often  mistaken  for  ague;  and  the  rapid  elevation  of  temperature, 
and  hard,  bounding  pulse  may  strengthen  the  suspicion.  The  headache 
continues,  and  is  still  not  confined  to  any  particular  locality,  but  is  so  intense 
that  the  patient  peeks  his  bed,  where  he  may  lie,  moaning,  sighing,  or  toss- 
ing restlessly  to  and  fro.  The  muscles  of  the  legs  may  twitch,  and  the 

1  Archiv  der  Hcilkunde,  1862. 


ACUTE    CEREBRAL    MENINGITIS.  45 

least  noise,  such  as  the  creaking  of  a  door,  invariably  irritates  and  startles 
the  invalid ;  bright  lights  distress  him,  and  he  closes  his  eyes  instinctively. 
He  keeps  his  hands  over  his  ears  so  that  he  may  not  hear  noises  in  the 
room,  or  firmly  presses  his  aching  temples.  There  maybe  vomiting  which 
is  not  dependent  upon  the  condition  of  the  stomach,  is  not  attended  by 
retching,  and  occurs  whether  the  stomach  be  empty  or  full.  If  the  patient 
be  a  child,  there  are  generally  convulsions  of  a  very  violent  character. 
These  constitute  the  first  stage. 

Active  delirium  usually  appears  during  the  first  two  days,  and  continues 
through  the  greater  part  of  the  second  stage.  The  patient  screams  in  an 
agonizing  manner,  and  alarms  those  who  may  be  with  him,  adding  greatly- 
to  the  distressing  character  of  his  sufferings.  The  delirium  now  begins  to 
subside,  or  may  be  supplanted  by  coma.  The  temperature  becomes  lower, 
and  the  pulse  loses  much  of  its  force  and  rapidity.  The  head  is  hot,  and 
the  respiration  becomes  irregular  and  sighing.  The  bowels,  which  were 
constipated  in  the  first  stage,  still  continue  so,  and  the  tongue  is  coated 
with  a  dirty-white  fur.  There  may  be  convulsions  at  this  time  which 
Txamskill1  says  may  precipitately  throw  the  patient  into  the  third  stage, 
which  is  one  of  collapse.  This  stage  may  resemble  that  of  advanced  ty- 
phoid. Sordes  on  the  teeth,  pinched  features,  dark  circles  about  the  eyes, 
fluttering  pulse,  great  prostration  with  loss  of  muscular  power,  dilated 
pupils,  stertorous  breathing,  and  the  unconscious  passage  of  feces  and 
urine,  are  all  forerunners  of  death.  Should  the  force  of  the  inflammation 
be  exerted  at  the  base,  the  symptoms  are  much  more  violent,  and  para- 
lyses of  cranial  nerves  are  not  uncommon. 

Causes In  considering  the  predisposing  causes  of  acute  meningitis 

it  will  be  well  to  inquire  what  are  the  influences  of  sex  and  age.  The  re- 
ports of  the  New  York  Board  of  Health  show  that  during  the  years  .1867, 
1868,  1870,  1871,  1872,  and  1873  there  were  4321  deaths  from  menin- 
gitis in  the  city  of  New  York,  2506  of  whom  were  males,  and  1815  females  ; 
3434  were  children  under  5  years;  of  these  1873  were  males,  and  1561 
females.  It  will  therefore  be  seen  that  males  are  more  often  affected  than 
the  other  sex,  and  that  the  large  proportion  of  cases  occur  among  children. 

Eilliet  and  Barthez  take  an  opposite  view  of  the  matter,  and  consider 
the  disease  to  exist  more  frequently  after  the  fifth  year.  My  own  expe- 
rience and  the  Health  Board's  statistics  lead  me  to  think  that  after  this 
period  of  early  life,  the  adult  cases  are  comprised  in  the  interval  between 
the  twentieth  and  fiftieth  years,  and  I  am  unable  to  find  the  records  of  many 
cases  after  the  sixtieth  year,  and  am  therefore  disposed  to  believe  that  the 
disease  is  rare  after  that  time.  Various  predisposing  causes  give  rise  to  the 
affection,  and  none,  I  think,  plays  a  more  important  part  in  the  production 
of  the  adult  variety  than  continued  dram-drinking  and  hard  work  in  warm 
places.  Over-use  of  the  mental  powers,  and  various  disorders,  such  as 
syphilis  and  gout,  are  favorable  to  its  development. 

Croupous  pneumonia,  acute  rheumatism,  diphtheria,  extension  of  dis- 

1  Article  in  Reynolds'  System  of  Medicine,  p.  369,  vol.  ii. 


46  DISEASES    OP    THE    CEREBRAL    MENINGES. 

ease  from  the  tympanic  cavity,  blows  upon  the  head,  and  sudden  changes 
of  temperature  of  any  kind,  are  the  direct  causes  of  acute  meningitis.  In 
one  of  my  cases  the  disease  was  the  result  of  a  sea-luith/  The  patii-nt. 
after  bathing,  sat  for  some  time  with  uncovered  head  upon  the  bench  <  x- 
posed  to  the  heat  of  a  noonday  sun.  Haeddeus1  reports  a  case  of  this 
disease  which  resulted  from  typhoid  fever. 

Diagnosis Acute  cerebral  meningitis  may  be  mistaken  or  con- 
founded with  cerebritis,  typhoid  fever,  or  delirium  tremens.  The  <ldi- 
rium,  headache,  and  disorders  of  motility  are  much  less  marked  in  cerebri  I  is 
than  in  acute  meningitis,  and  it  must  be  remembered  that  the  pulse  in  the 
latter  disease  is  much  more  rapid  and  full,  and  the  temperature  much 
higher. 

Typhoid  fever  is  symptomatized  by  elevation  of  evening  temperature, 
diarrh<ca,  abdominal  tenderness  and  tympanitis,  muttering  delirium,  and 
the  presence  of  petechize.  Delirium  tremens  may  be  occasionally  con- 
founded with  the  disease  under  discussion,  but  it  must  be  remembered 
that  the  history  of  alcoholism — peculiar  delusions  and  alcoholic  delirium, 
the  absence  of  headache  and  the  condition  of  the  skin,  are  all  evidences  of 
delirium  tremens,  which  are  not  to  be  mistaken. 

Pathology  and  Morbid  Anatomy. — When  the  pia  mater  and 
arachnoid  become  the  seat  of  inflammation,  we  may  roughly  group  the 
lesions  and  consequent  symptoms  into  two  classes,  one  indicative  of  basal 
trouble  and  the  other  of  vertical.  In  the  former,  cranial  nerve-trunks 
will  be  injured  or  diseased ;  while  in  the  latter,  the  investing  membranes 
of  the  cerebrum  will  be  the  seat  of  morbid  action,  and  the  functions  of  the 
cortex  must  be  consequently  destroyed,  so  that  the  symptoms  will  be  more 
of  a  psychical  character  than  when  the  base  is  involved. 

The  recent  investigations  and  contributed  cases  of  Landouzy,9  of  which 
104  are  presented  by  this  author,  demonstrate  the  connection  between  cer- 
tain symptoms  and  lesions  of  the  description  to  be  hereafter  mentioned,  in- 
volving those  portions  of  the  cortex  containing  the  centres  of  Hitzig3  and 
Fritsch.  These  prove  very  clearly  that  violence  of  the  inflammatory  pro- 
cess in  certain  places  may  be  attended  by  certain  paralyses  or  contrac- 
tions of  limbs  which  are  innervated  from  these  centres.  A  case  which 
recently  came  under  my  observation  is  one  of  this  kind,  and  possesses 
great  pathological  interest. 

E.  B.,  aged  thirty-six,  born  in  Ireland,  by  occupation  a  blacksmith,  is 
a  stout,  well-made  man  of  nervous  temperament,  and  up  to  the  commence- 
ment of  his  present  trouble  had  enjoyed  uninterrupted  good  health.  lie 
has  not  had  syphilis,  and  his  habits  have  been  good.  His  mother  and 
father  are  dead,  the  former  having  died  of  old  age  and  the  latter  of  phthi- 
sis. There  is  no  family  history  of  insanity,  epilepsy,  paralysis,  nor  of  any 

1  Berliner  Klin.  Woch.  18G9,  p.  5G4. 

2  Contribution  &  l'£tudc  des  Convulsions  ut  Paralysis  Ii6es  aux  Meningo-enceph- 
litis  tYonto-parietalos.     Paris,  1876. 

8  lleichert  and  Du  Bois  Raymond's  Archives,  1870,  Heft  3. 


ACUTE    CEREBRAL    MENINGITIS.  47 

organic  nervous  trouble  .whatever.  Ten  years  ago,  while  working  upon  a 
fire-escape,  he  tell  to  the  ground,  two  stories  below,  striking  upon  his  head 
and  shoulder.-  He  was  taken  up  unconscious,  and  remained  so  for  four- 
teen hours.  The  only  injuries  lie  received  were  two  severe  scalp-wounds, 
one  of  which  from  its  slowness  in  healing  must  have  been  attended  by 
some  bone  injury,  for  he  was  unable  to  resume  work  until  three  months 
later.  He  says  that  purulent  accumulations  took  place,  and  that  "  the 
doctor  lanced  them."  Two  cicatrices  are  now  visible,  one  of  which  is 
about  an  inch  and  a  half  long,  and  is  situated  on  the  left  side  of  the  head 
and  covers  a  depression  about  three-quarters  of  an  inch  in  diameter  and 
one-quarter  of  an  inch  in  depth,  the  centre  of  which  is  about  one  and  one- 
half  inches  below  the  median  line,  five  inches  above  the  left  ear,  and  four 
and  three-quarters  inches  above  the  centre  of  the  left  supra-orbital  arch. 
This  is  the  only  depression  visible,  and  the  injury  on  the  right  side  was 
apparently  very  superficial. 

He  gives  no  history  of  serious  head  symptoms,  and  when  he  resumed 
work  was  in  good  condition,  there  being  no  paralysis.  About  three  months 
later  he  noticed  a  tremulousness  of  the  fingers  of  the  right  hand,  and 
afterwards  of  the  arm  of  the  same  side.  There  was  no  pain  nor  loss  of 
power,  but  simply  a  marked  tremor  whenever  he  attempted  to  do  any- 
thing. This  difficulty  increased  to  such  an  extent  that  he  was  obliged  to 
resign  his  position  as  first-class  workman,  and  become  a  helper,  using  his 
other  arm  to  work  the  bellows.  About  six  months  after  this  the  tremor 
affected  the  right  leg,  and  he  was  obliged  to  leave  his  work. 

Present  Condition — The  patient  does  not  complain  of  head  symptoms, 
except  a  slight  hypera?sthesia  of  the  right  side  of  the  face,  of  short  dura- 
tion. Vision  normal ;  fundus  of  either  eye  presents  no  abnormal  appear- 
ances ;  pupils  respond  well  to  light,  and  are  of  equal  size.  Hearing 
unaffected.  No  tremor  of  face  or  tongue,  speech  unembarrassed,  memory 
good,  and  no  intellectual  trouble  whatever.  He  has  never  had  headache. 

Upper  Extremities — Left  side  unaffected.  The  right  hand  and  arm 
are  perfectly  quiet  during  inaction,  but  when  the  most  simple  voluntary 
act  is  attempted  they  become  agitated  by  a  fine  rhythmical  tremor,  which 
becomes  more  marked  as  the  accomplishment  of  the  act  requires  greater 
nicety  of  coordination.  When  he  is  asked  to  carry  a  glass  of  water  to  his 
mouth,  he  spasmodically  grasps  the  vessel  and  carries  it  upward,  the  elbow 
being  raised,  the  tremor  meanwhile  increasing  until  the  mouth  is  reached, 
when  the  movements  become  so  violent  that  he  is  unable  to  place  the  rim 
of  the  glass  between  his  lips.  Certain  motions  are  almost  entirely  unat- 
tended by  tremor.  He  can  extend  the  arm  and  hand,  or  can  hold  them 
rigidly  upright,  and  is  able  to  pronate  the  hand,  but  movements  of  flexion 
are  attended  by  increased  violence  of  the  tremor.  Tactile  sensation  is 
somewhat  impaired,  but  susceptibility  to  painful  impressions  is  not  dimin- 
ished. There  is  absolutely  no  loss  of  muscular  power,  no  atrophy  of  the 
hand  or  arm,  the  thenar  eminences  being  covered  by  firm  cushions,  and 
the  interosseous  spaces  being  well  filled. 

Lower  Extremities — The  left  leg,  like  the  arm,  is  in  no  way  affected. 
The  right  leg,  however,  is  agitated  by  muscular  tremor  when  he  attempts 
to  use  it,  or  approximates  it  with  its  fellow,  as  in  standing  erect.  There 
is  no  loss  of  muscular  power,  but  some  anaesthesia,  the  patient  being 
unable  at  any  place  to  distinguish  two  points  of  the  aesthesiometer,  unless 
they  are  separated  at  least  eight  centimetres. 

When  he  stands  with  his  eyes  closed  he  is  "groggy,"  but  does  not  fall. 


48  DISEASES    OF    THE    CEREBRAL    MENTNGES. 

He  can  stand  upon  the  right  foot  alone,  but  not  upon  the  left.  When  he 
walks,  the  right  heel  is  brought  down  first,  so  that  the  heel  of  the  shoe  is 
much  worn.  He  has  some  plantar  formication  and  coldness  of  the  foot. 
He  has  suffered  from  pains  of  a  pseudo-neuralgic  nature  in  the  right 
shoulder  and  right  thigh,  which  were  centrifugal,  as  well  as  some  pains 
which  darted  from  the  heel  up  the  inner  side  of  the  leg.  The  pains  in  the 
upper  extremity  are  not  so  frequent  as  they  were  a  year  ago.  There  has 
been  no  history  of  body-constricting  band,  pain  in  the  back,  or  vesical 
trouble  of  any  description,  but  for  the  past  five  years  he  has  been  consti- 
pated and  obliged  to  take  purgatives.  There  are  no  contractions  whatever. 

The  peculiarities  of  this  case  seem  to  be  the  unilateral  tremor  (not  dis- 
orderly movements)  excited  by  voluntary  exertion,  its  predominance  in 
flexion,  while  certain  movements  of  extension  are  almost  unattended  by 
any  embarrassment,  the  absence  of  muscular  weakness,  contractions,  or 
atrophy,  and  the  evident  dependence  of  the  trouble  upon  a  localized  cere- 
bral injury  of  the  opposite  side,  which  probably  resulted  from  the  fall. 

I  am  unable  to  arrive  at  any  conclusion  which  would  lead  me  to  con- 
sider the  symptoms  due  to  cerebro-spinal  sclerosis,  or  one-sided  posterior 
spinal  sclerosis,  if  the  latter  anomalous  condition  could  exist.  The  utter 
absence  of  loss  of  power  and  permanent  contraction  of  the  affected  limbs, 
and  the  non-extension  of  the  affection  to  those  of  the  other  side  of  the 
body  within  ten  years,  are  sufficient  to  invalidate  such  a  diagnosis. 

The  non-occurrence  of  convulsions  and  other  symptoms  of  cerebral 
tumor  renders  this  as  a  cause  of  the  tremor  quite  improbable. 

Of  course  the  assumption  that  this  patient's  symptoms  are  due  to  some 
irritative  meningeal  or  cortical  lesion  must  be  based  upon  purely  theoreti- 
cal grounds,  but  the  features  of  the  case  convince  me  that  such  a  condition 
of  affairs  is  by  no  means  improbable.  If  we  take  the  trouble  to  consult 
the  charts  of  Hitzig  and  Ferrier,  we  shall  find  that  they  have  assigned  a 
cortical  region  which  is  "situated  on  the  ascending  frontal,  just  behind 
the  upper  end  of  the  posterior  extremity  of  the  middle  frontal  convolu- 
tion," which  "is  the  centre  for  the  movements  of  the  hand  and  forearm 
in  which  the  biceps  is  particularly  engaged,  namely,  supination  of  the 
hand  and  flexion  of  the  forearm."1  Again,  if  we  consult  the  admirable 
article  of  Turner,*  we  shall  find  very  useful  hints  which  will  enable  us  to 
lay  out  the  exterior  of  the  cranium  into  regions  corresponding  with  the 
convolutions  beneath.  One  of  these  areas,  which  has  been  called  the 
upper  antero-parietal  space,  includes  the  ascending  parietal  and  ascending 
frontal  convolutions,  and  an  injury  at  the  point  I  have  located  in  describing 
this  case  would  be  just  over  the  centre,  which,  when  experimentally  irri- 
tated, produces  movements  of  flexion  and  supination. 

It  is  quite  reasonable  to  suppose  that  this  irritation  occurring  with  voli- 
tional movements  is  due  to  a  natural  increase  in  the  blood  pressure  during 
mental  activity,  a  consequent  increase  in  cerebral  volume,  and  a  resulting 
meningeal  contact  witli  the  depressed  portion  of  bone,  which  probably 
does  not  impinge  upon  the  cranial  contents  at  ordinary  times. 

In  the  majority  of  cases  the  inflammation  begins  at  the  base  and  extends 
upwards.  The  temporal  lobe  may  often  be  its  starting-point,  while  in 

1  Functions  of  the  Brain,  page  307. 

2  Journal  of  Anatomy  and  Physiology,  vols.  xiii.,  xiv.,  November,  1873,  May, 
1874. 


ACUTE    CEREBRAL    MENINGITIS.  49 

other  varieties  the  meninges  covering  the  cerebellum  may  alone  be  in- 
volved. The  appearance  of  the  cranial  contents  cannot  be  mistaken,  the 
membranes  are  red,  hypertemic  and  attached  to  each  other,  and  the  arach- 
noid cavity  contains  a  considerable  quantity  of  serum.  The  fluid  in  the 
ventricles  is  increased  and  may  contain  pus,  and  the  choroid  plexuses 
are  found  to  be  turgescent  and  enlarged.  It  may  be  stated  upon  the  au- 
thority of  Huguenin1  that  in  some  cases  the  intra- ventricular  fluid  is  puru- 
lent on  one  side,  while  it  may  be  simply  serous  on  the  other.  In  aggra- 
vated cases  the  quantity  of  pus  may  be  considerable,  and  if  the  meningitis 
be  of  the  basilar  form  the  pia  mater  of  the  base  will  exhibit  extensive 
purulent  infiltration.  The  ependyma  of  the  ventricles  may  be  thick- 
ened, and  contains  yellowish  deposits.  In  cases  due  to  traumatism,  or  ex- 
tension of  other  diseases,  there  may  be  found  evidences  of  caries  or  fracture. 
The  cortex  in  nearly  every  case  of  meningitis  of  the  convexity  is  found  to 
have  undergone  decided  softening,  and  when  the  meninges  are  removed, 
some  of  the  superficial  brain -substance  is  carried  with  them. 

Prognosis We  should  always  hesitate  in  expressing  our  opinion  as 

to  the  course  of  the  disease,  although  so  few  cases  get  well  that  it  is  almost 
safe  to  say  that  our  patient  cannot  recover.  If  the  patient  improves  after 
the  first  week,  we  may  consider  the  prognosis  much  more  hopeful,  but 
there  are  often  deceitful  lulls  which  may  mislead  the  medical  attendant. 
If  active  treatment  produces  beneficial  results,  his  chances  are  better,  while 
any  evidence  of  ocular  trouble,  and  consequently  basal  involvement,  lessens 
the  patient's  chances  materially.  Should  the  disease  result  from  extension 
of  inflammation  of  the  temporal  bone,  the  prognosis  is  also  grave.  Death 
may  occur  in  four  or  five  days,  or  even  in  a  shorter  time,  but  the  duration 
of  the  disease  may  extend  to  the  tenth  day. 

Treatment — Two  indications  are  to  be  met  promptly  :  one  the  ab- 
straction of  blood ;  the  other,  cold  to  the  head.  When  the  delirium  is 
furious,  temporal  vessels  swollen,  and  the  pulse  hard  and  bounding,  ab- 
straction of  blood  from  the  arm  is  to  be  immediately  resorted  to.  A  sug- 
gestion made  by  Holland  many  years  ago  is  one  of  value,  notwithstanding 
the  fact,  that  it  has  been  almost  forgotten  and  generally  disregarded.  I 
allude  to  the  application  of  leeches  to  the  haemorrhoidal  veins ;  to  use  his 
words :  "  I  know  of  no  mode  in  which  a  given  quantity  of  blood  can  be 
removed  with  equal  effect  in  cases  where  it  is  required."2  Cold  to  the 
scalp  either  by  ice-bags,  or  by  a  bladder  filled  with  pounded  ice,  or  an 
arrangement  of  rubber  tubes,  should  be  employed,  and  will  be  found  to 
very  speedily  relieve  the  pain.  Accepting  a  hint  from  Dr.  Chamberlain, 
of  this  city,  I  have  had  constructed  and  successfully  used  an  apparatus  such 
as  I  will  describe.  It  consists  of  a  long  piece  of  rubber  tubing  wound  upon 
itself  and  securely  held  in  its  spiral  form  by  tape,  forming  a  skullcap.  The 
upper  end  is  connected  with  an  ice-cooler  or  a  cold  water  tap,  should  there 
be  one  in  the  apartment ;  and  the  other  is  fitted  with  a  stopcock  so  that 

1  Ziemssen's  Encyclopaedia,  vol.  xii.,  translation. 

2  Quoted  by  Solly.     The  Human  Brain,  etc.,  page  353. 


50  DISEASES    OF    THE    CEREBRAL    MENINOES. 

the  discharge  of  water  may  be  regulated.  By  this  means  the  patient's 
head  can  be  kept  cool  and  his  bed  dry  and  comfortable,  an  impossible 
state  of  affairs  when  the  douche  is  used.  Iodide  of  potassium  in  large 
doses  has  been  given  with  excellent  effect,  and  its  efficacy  in  this  disc.-i-- 
has  been  praised  by  Flint,  Alonzo  Clark,  and  others.  Aconite,  ergot,  and 
the  bromides  are  all  efficient  remedies  in  depressing  the  pulse  and  quelling 
the  delirium;  and  elaterium  (F.  22),  saline  cathartics,  or  the  old  combina- 
tion of  salts  and  senna  (F.  41)  may  be  of  service.  Blisters  applied  behind 
the  ears  and  to  the  neck  are  excellent  adjuvants.  Should  the  patient's 
strength  be  reduced,  as  is  the  case  in  the  later  stages,  the  free  use  of 
stimulants,  nourishing  food,  such  as  milk,  egg-nog,  beef-broths,  and  nutri- 
tious but  digestible  food,  are  of  great  importance.  In  the  other  forms 
presently  to  be  alluded  to,  we  should  be  governed  by  the  existence  of  rheu- 
matism, or  the  advanced  age  of  the  patient,  and  for  the  former  prescribe 
alkalies,  colchicum,  and  other  remedies  of  the  same  nature,  and  for  the  latter 
a  generous  diet  and  a  liberal  use  of  stimulants.  (F.  17,  F.  45.) 


RHEUMATIC  MENINGITIS. 

A  form  of  inflammation  of  the  meninges  may  be  connected  with,  or 
occur  during  the  course  of  acute  articular  rheumatism,  or  again  it  may  be 
found  without  any  coexisting  joint  trouble. 

Trousseau1  has  described  three  forms  of  cerebral  rheumatism.  One  of 
these  he  calls  apoplectic,  and  it  is  symptomatized  by  coma  without  paraly- 
sis ;  a  second  form,  first  described  by  Gosset,  is  that  in  which  delirium 
is  followed  by  coma  ;  and  there  is  a  third  in  which  delirium  makes 
its  appearance  in  the  course  of  inflammatory  rheumatism.  Its  co- 
existence with  joint-trouble  is  by  no  means  the  rule,  though  the  majority 
of  cases  reported  have  been  of  this  character.  Posner2  reports  a  case  in 
which  the  inflammation  left  the  joints  and  attacked  the  meninges.  Pain 
in  the  head,  delirium,  and  slow  pulse  were  the  prominent  features  of  the 
patient's  illness,  and  recovery  took  place  in  about  two  weeks.  The 
symptoms  of  an  attack  of  metastatic  rheumatic  meningitis  are  these : 
Either  during  an  attack  of  acute  rheumatism,  or  afterwards,  the  patient 
may  become  dull  and  stupid,  and  delirium  makes  its  appearance.  This 
delirium  is  of  a  violent  character,  and  during  its  existence  the  patient 
may  have  delusions  and  hallucinations  of  sight  and  hearing.  In  a  case 
reported  by  Me/net*  the  delusions  of  persecution  were  a  prominent  fea- 
ture, but  there  is  no  regularity  in  their  mode  of  expression.  There  is 
usually  but  a  slight  rise  of  temperature,  though  it  may  sometimes  attain 
an  elevation  of  106°,  or  thereabouts,  and  the  pulse  at  the  same  time  be- 
comes very  rapid  and  full.  Headache  of  a  severe  variety,  such  as  I  have 
described  when  speaking  of  the  other  forms  of  acute  meningitis,  may  be 

1   Rhoumatismtis  Ci-rehralis,  Schmidt's  Jahresbericht,  vol.  113,  p.  25. 
*  Knct'phalopathia  Rheumatica,  Ibid.,  vol.  104,  p.  167. 
3  Archives  G6n6rales,  June,  1856. 


RHEUMATIC    MENINGITIS.  51 

present  throughout  the  illness,  and,  after  several  days,  choreaform  move- 
ments may  occur,  and  with  their  advent  the  delirium,  which  was  before 
inconstant,  now  becomes  continuous.  These  choreaform  movements  are 
such  as  a  nervous  embarrassed  person  would  make  in  health  when  sud- 
denly disconcerted.  There  is  an  uneasy  opening  and  closing  of  the  fingers, 
and  the  arm  is  jerked  backwards  and  forwards.  The  patient  now  finds 
considerable  difficulty  in  swallowing,  portions  of  food  remaining  in  the 
mouth  for  some  time.  Great  prostration  and  collapse  may  supervene,  and 
the  patient  dies  in  a  comatose  state,  or,  on  the  other  hand,  there  may  be 
slow  recovery,  the  mental  symptoms  being  the  last  to  subside. 

Vomiting  and  early  headache,  which  are  so  characteristic  of  the  other 
forms  of  meningitis,  are  absent.  Recovery  is  rare,  and  of  thirty-nine 
cases  reported  by  Vigla,1  thirty  terminated  fatally.  Should  the  patient 
survive,  he  is  very  apt  to  become  insane,  the  variety  of  such  mental 
trouble  being  chronic  mania.  Huguenin2  considers  that  the  connection  of 
meningitis  with  rheumatism  is  threefold  : — 

"  a.  Endocarditis  is  the  connecting  link,  so  that  the  combination  is 
rheumatism,  ulcerative  endocarditis,  meningitis. 

"  b.  Purulent  inflammations  of  the  serous  membranes  form  the  connect- 
ing link,  endocarditis  being  present  or  not,  as  may  be.  In  this  case  puru- 
lent meningitis  is  secondary  to  purulent  inflammation  of  the  serous  mem- 
branes ;  this  is  very  rare,  and  the  exact  connection  is  unknown.  (An 
observation  of  our  own,  in  which  the  coincidence  was  striking,  but  the 
manner  of  transmission  obscure.) 

"  c.  Meningitis  complicates  rheumatism  without  there  being  any  puru- 
lent deposits  in  the  body,  or  any  affection  of  heart ;  the  connection  here  is 
also  obscure." 

Da  Costa3  is  inclined  to  refer  the  brain  symptoms  in  cerebral  rheuma- 
tism to  two  agencies,  the  first  of  which  is  a  circulation  of  vitiated  blood, 
and  the  second  is  the  disturbance  of  cerebral  circulation  dependent  upon 
the  plugging  of  small  arteries  by  fine  embola,  and  consequently  considers 
cerebral  rheumatism  to  be  a  disease  which  is  not  essentially  an  inflamma- 
tion of  the  cerebral  meninges. 

A  case  of  rheumatic  meningitis  which  recovered  under  the  use  of  cold 
baths — and  was  treated  by  M.  Fe're'ol,4  of  Paris — is  the  following  : — 

The  patient  was  thirty -four  years  old,  of  quiet  and  temperate  habits, 
who  was  suffering  from  acute  articular  rheumatism.  He  was  treated  at 
first  with  emetics,  sulphate  of  quinine,  and  colchicum,  but  in  five  days  he 
was  seized  with  delirium,  agitation,  and  dyspmea,  and  at  the  same  time 
the  pains  in  the  joints  disappeared.  The  temperature  of  the  body  rose  to 
forty  degrees  (Centigrade),  and  leeches,  calomel,  and  bromide  of  potas- 
sium were  given  without  success.  The  temperature  rose  further  to  forty- 
one  degrees,  and  blisters  were  placed  on  the  scalp,  and  digitalis  was 

1  Aetes  de  la  Soc.  Med.  des  HSpitaux  de  Paris,  1865,  3me  fas. 

2  Op.  cit.,  p.  624. 

3  American  Journal  Med.  Sciences,  Jan.  1875. 

4  Bull.  Gen.  de  Th6rap.,  Mar.  30,  1875.     Med.  News,  1875. 


52  DISEASES    OF    THE    CEREBRAL    MEN1NQE8. 

given.  There  was  then  a  little  more  rest,  but  the  aspect  was  typhous, 
with  stupor  and  continuous  sub-delirium  ;  sleeplessness,  agitation  of  the 
muscles,  subsultus  tendinum,  dry  tongue,  etc.  After  some  consultation 
witli  other  physicians  it  was  determined  to  try  the  effects  of  cold  baths  as 
the  only  remaining  resource.  This  plan  was  pursued  for  a  whole  week. 
the  patient  remaining  under  close  observation  the  whole  of  the  time,  ami 
the  thermometer  being  almost  fixed  under  the  axilla.  As  soon  as  the 
temperature  rose  to  39.o°  the  patient  was  plunged  into  a  cold  bath.  From 
the  2f>th  of  February  to  the  3d  of  March  sixteen  baths  were  administered 
at  a  temperature  varying  from  twenty-one  to  twenty-five  degrees  (Centi- 
grade), and  the  duration  of  each  bath  was  twenty  minutes  on  the  average. 
The  patient  always  raised  the  temperature  of  the  water  from  one  to  two 
degrees,  and,  on  leaving  the  bath,  his  own  temperature  fell  to  thirty-six 
degrees.  After  several  fluctuations  and  much  anxiety  on  the  part  of  the 
medical  attendants,  the  patient  eventually  recovered  completely. 

MENINGITIS  OF  THE  AGED. 

According  to  Prus,1  meningitis  of  the  aged  rarely  presents  the  same 
symptoms  as  do  the  forms  of  early  or  middle  life.  In  the  morning  the 
old  man  or  woman  is  stupid,  but  conscious ;  speech  is  thick,  and  there  is 
general  headache  and  moderate  fever.  The  warmth  of  the  body  is  nearly 
normal,  except  at  the  head,  where  it  is  markedly  increased.  In  the  even- 
ing it  is  elevated. 

The  eyes  are  injected,  and  there  is  low  delirium.  Incoherency  and 
restlessness,  during  the  night,  and  an  uneasiness  which  is  expressed  by 
walking  about  the  house  and  going  from  one  bed  to  the  other,  are  mani- 
festations which  are  characteristic.8  If  the  disease  is  to  end  fatally,  the 
patient  becomes  comatose,  and  dies  within  a  week,  or  twenty  days  at  the 
longest,  from  the  commencement  of  the  disease.  These  patients  very 
often  suffer  for  some  time  before  the  actual  attack,  when  there  may  be 
partial  paralysis,  slight  wandering  of  the  mind,  and  insomnia.  The  gene- 
ral indications  for  treatment  of  the  other  forms  are  applicable  in  these 
cases. 


ACUTE  GRANULAR  (TUBERCULAR)  MENINGITIS. 

Dr.  Robert  "VVhytt'was  the  first  to  describe  this  disease,  and  so  satisfac- 
torily did  he  do  so,  that  even  after  a  hundred  years  there  is  very  little  to 
add  to  his  accurate  description.  AVe  shall  have  to  study  the  disease  as 
occurring  in  two  different  ways.  It  may  be  primary,  and  have  a  doubt- 
ful tubercular  character,  or  may  occur  in  connection  with  some  thoracic 

1   Quoted  by  Grisollc,  vol.  i.  p.  430. 

*  Kamskill  speaks  of  the  eccentric  behavior  of  these  patients,  who  may  use  the 
spittoon  instead  of  the  chamber  pot,  or  commit  other  violations  of  decency.  In 
one  case  which  came  to  my  knowledge,  the  patient  urinated  against  the  bed-post, 
and  went  about  the  house  with  his  trowsers  unbuttoned. 

3  Works  of  Dr.  Whytt,  Edinburgh,  1768. 


ACUTE    GRANULAR    MENINGITIS.  53 

or  abdominal  disease,  and  like  the  other  forms  of  meningitis,  may  be  con- 
fined to  the  base  or  convexity. 

Symptoms Though  many  of  the  symptoms  are  the  same,  there  are 

a  few  general  points  of  difference,  which  are  the  following : — 

Predominant  Symptoms. 

BASAL.  VERTICAL. 

Vomiting,  constipation,  infrequent  or  Convulsions  with  intervals  occupied 
irregular  pulse,  unequal  pupils,  stra-  by^remor,  twitching  of  limbs  and  mus- 
bismus.  cles  'of  face,  turning  of  thumbs  in  on 

palms,  clenching  of  fists,  frequent  pulse. 

"When  the  base  is  involved,  the  symptoms  may  be  grouped  in  three 
stages,  which  run  their  course  in  from  four  to  twenty-one  days.  The 
child  may  be  puny  and  delicate.  He  may  lose  flesh  and  complain  of 
headache.  His  skin  may  be  white  and  waxy,  and  there  may  be  a  ten- 
dency to  flushed  cheeks,  loss  of  appetite,  and  capriciousness  about  food, 
and  at  night  he  does  not  sleep  soundly,  but  starts  and  cries  out.  I  have 
known  children  to  seek  the  companionship  of  some  other  member  of  the 
family,  fearing  to  be  left  alone.  The  child  may  moan  in  its  sleep,  grind- 
ing his  teeth  and  lying  with  eyes  widely  opened.  During  the  day  he  is 
disinclined  to  play,  and  seeks  some  quiet  place  in  which  to  fall  asleep  or 
remain  by  himself.  Study  is  irksome,  and  so  are  all  other  forms  of  men- 
tal application.  Irritable  or  languid,  he  attracts  the  attention  of  the 
mother  by  his  behavior,  which  is  so  markedly  changed.  During  this 
period  I  have  found  that  headaches  and  crying-spells  are  not  uncommon 
precursors  of  the  next  stage,  which  may  begin  after  two  or  three  months. 

Stage  of  Development — Marshall  Hall,1  in  his  description  of  the 
hydrocephaloid  diseases,  alludes  to  the  importance  of  vomiting  as  an  early 
symptom.  "  The  most  frequent  and  formidable  in  appearance 
is  vomiting.  Never,  never  allow  vomiting  in  an  infant  to  pass  without 
paying  the  utmost  attention,  and  making  the  strictest  inquiry  in  refer- 
ence to  the  functions  of  the  brain."  Vomiting  is  generally  the  first  and 
most  important  symptom,  and  convulsions  are  next  in  importance,  but 
these  two  may  be  associated  or  appear  alone.  Vomiting  may  be  frequent, 
and  is  nearly  always  accompanied  by  an  aggravation  of  the  symptoms 
of  the  premonitory  stage.  Headache  and  increased  temperature  are  pre- 
sent, and  are  very  decided  evidences  of  the  gradual  development  of  the 
trouble.  When  we  arrive  at  this  stage,  which  lasts  two  or  three  days, 
we  may  expect  the  appearance  of  the  following  symptoms :  A  marked 
rise  of  temperature,  say  from  101°  to  105°  F.,  with  greatly  increased 
pulse.  The  bowels  are  still  constipated,  and  there  is  but  little  appetite. 
The  patient  is  delirious  at  night,  and  shrieks,  cries,  and  tosses  continu- 
ally. At  about  the  sixth  or  seventh  day,  there  are  various  local  troubles, 
such  as  unequally  dilated  pupils,  slight  strabismus,  but  no  actual  loss  of 
consciousness  as  yet.  There  is  a  slight  increase  in  the  evening  tempe- 

1  Lecture  on  the  Nervous  System  and  its  Diseases,  L.  and  E.  Philadelphia, 
1836,  p.  92. 


54  DISEASES    OF    THE    CEREBRAL    MENINGES. 

rature,  and  the  pulse  is  irregular  and  ranges  from  110  to  120.  The  tenth 
day  finds  him  much  worse  ;  his  excited  condition  being  supplanted  by  one 
of  stupidity.  He  does  not  recognize  those  in  the  room,  and  is  utterly 
indifferent  to  the  kind  attentions  of  his  mother  or  nurse.  "When  the 
finger  is  drawn  across  the  skin  it  leaves  a  vivid  red  mark,  which  lias  been 
considered  one  of  the  strong  pathognomonic  signs.  The  pulse  is  greatly 
accelerated,  and  perhaps  reaches  170,  while  the  temperature  may  be  found 
to  be  104°  or  105°.  His  condition  during  the  tenth  and  eleventh  days 
is  very  little  changed,  though  the  apathy  is  if  anything  exaggerated.  The 
belly  is  retracted,  and  his  facies  is  highly  characteristic,  the  patient  having 
a  worn  and  pinched  look.  The  skin  is  dark  and  congested,  and  his  eyes 
may  be  fixed  and  immobile,  and  there  may  be  either  strabismus  or  a 
rolling  upwards  of  both  eyeballs,  so  that  a  large  part  of  the  sclerotic  is 
exposed.  Subsultus  tendinum  and  "  picking  at  the  bedclothes,"  with 
involuntary  passage  of  feces  and  urine,  are  grave  forerunners  of  a  fatal  ter- 
mination. The  pupils  are  dilated,  the  pulse  small,  thready,  and  quick, 
and  respiration  is  very  slow.  The  temperature  is  still  high,  though  the 
surface  may  be  cold  and  clammy,  and  just  before  death  the  pulse  quickens 
and  becomes  almost  imperceptible.  Slight  rigidity  now  becomes  apparent, 
the  patient  cannot  swallow,  stertor  follows,  and  then  death.  Marshall 
Hall1  tersely  describes  this  last  stage  as  follows  :  "  The  third  stage  is 
denoted  by  coma  and  its  concomitant  diminution  of  the  sentient  and  volun- 
tary system,  and  eventually  of  the  powers  of  the  excito-motory  system. 
There  are  blindness,  deafness,  deep  stupor,  absence  of  voluntary  motion. 
At  first  the  eyelids  are  constantly  half  closed,  but  still  close  completely  on 
touching  the  eyelash.  Afterwards  this  excito-motory  phenomenon  ceases. 
The  respiration  becomes  irregular,  alternately  suspended  and  sighing,  and 
at  length  stertorous.  The  sphincters  lose  their  power,  and  the  feces  and 
urine  are  passed  unconsciously."  The  appearance  of  the  little  patient 
just  before  death,  is  unmistakable.  He  lies  with  knit  brow  and  flushed 
face,  one  side  of  which  is  drawn,  while  the  eyes  are  fixed  and  glassy,  and 
utterly  devoid  of  expression. 

The  duration  of  the  disease  rarely  exceeds  twenty-four  days.  It  will 
be  well  to  dwell  more  fully  upon  certain  symptoms.  Temperature. — There 
seems  to  be  at  first  an  elevation  of  temperature,  which  lasts  through  the 
first  few  days,  say  three  or  four,  and  after  this  time  the  temperature  falls, 
until  the  sixteenth  or  eighteenth  day,  when  it  may  either  go  much  lower, 
or  be  again  increased.  The  variations  are  between  the  normal  standard 
98.2°,  and  105°.  It  however  rarely  reaches  this  high  point.  The  sur- 
face temperature  of  the  body  is  much  diminished  during  the  latter  stages, 
but  the  head  is  always  hot.  Pulse — Infrequent  and  irregular  pulse  is 
characteristic  of  the  earlier  stages  of  this  disease,  and  during  the  last  days 
there  is  increased  frequency  and  more  evenness.  During  the  first  two 
weeks  this  infrequency  is  to  be  observed,  but  after  this  it  may  steadily 
increase  ten,  twenty,  or  thirty  beats  more  each  day  until  at  last  it  cannot 

1  Op.  cit.,  p.  93 


ACUTE    GRANULAR    MENINGITIS. 


55 


be  counted.  This  rule  is  not  without  its  exception,  and  I  have  found 
intervals  when  both  temperature  and  pulse  would  fall  to  the  normal  stand- 
ard, and  continue  so  for  some  days,  and  afterwards  rise.  The  pulse  is 

Illustrative  Chart  of  Temperature. 
Pulse  and  Respiration  Variations  in  Acute  Granular  Meningitis. 


Days  of 
Disease. 


Sjior 

S  |106C 


H  105° 


*  104° 


103 


99 


98 


180 


170 


160 


150 


120 


110 


100 


90 

80 


70 


60 


50 


I    45 

!  I 

40 


35 


30 

_?! 

2Q_ 
15 


^ 


\ 


2. 


/q/3/4 


MEMEMEME 


/6 


n 


X. 

B- 


A.  Indicates  sthenic  chai-acter. 

B.  Indicates  irregularity. 

perhaps  more  rapid  when  the  disease  is  being  developed.     I  append  a 
chart,  which  will  enable  the  reader  to  see  at  a  glance  the  condition  of 


56  DISEASES    OF    THE    CEREBRAL    MENINOES. 

pulse,  temperature,  and  respiration  in  a  typical  case.  Various  modifica- 
tions of  the  cutaneous  circulation  have  been  dwelt  upon  by  Trousseau  and 
various  writers.  There  seems  to  be  an  extensive  disturbance  of  the  vaso- 
motor  distribution  of  the  skin,  and  when  the  surface  is  brushed  or  rubbed 
ever  so  lightly,  or  even  when  slight  pressure  has  been  made  by  the  pillow, 
there  will  remain  a  bright  red  mark.  This  condition  of  the  cutaneous  cir- 
culation is  not  limited  to  the  integument  of  the  head,  but  may  be  present, 
especially  towards  the  end  of  the  disease,  over  the  whole  body.  Trous- 
seau1 has  called  attention  to  the  "  tache-cerebrale,"  which  is  the  name 
given  to  the  appearance  presented  when  the  finger  is  passed  over  the  sur- 
face, and  a  red  line  remains. 

This  author  finds  that  when  he  made  cross-markings  upon  the  abdomen, 
in  less  than  half  a  minute  the  portion  of  skin  which  he  had  touched  was 
suffused  with  a  very  bright  red  tint,  which  disappeared  slowly,  the  lines  made 
by  the  finger-nails  remaining  after  the  others  had  faded  out.  The  regions 
where  this  redness  is  produced  most  easily  are  the  anterior  parts  of  the 
thighs,  the  abdomen,  and  face.  Respiration — There  are  the  usual  fall  and 
irregularity  which  accompany  collapse  of  all  kinds  ;  and  sighing  and 
diminished  respiration  are  features  of  the  later  stages.  Sensorial  Dis- 
turbances  Headache  of  a  deep  and  throbbing  character  is  very  severe 

and  continuous,  lasting  until  coma  supervenes.  Various  indications  of  the 
patient's  sufferings  are  conveyed  by  his  behavior.  He  presses  his  thumbs 
against  his  temples,  or  locking  his  finger  on  top  of  his  head,  holds  his  head 
in  his  hands,  and  gives  vent  to  suppressed  groans  or  shrieks,  holding  his 
breath  sometimes  as  if  fearing  that  the  very  effort  of  expiration  might 
increase  the  pain.  The  cry  of  the  patient  is  heart-rending,  but  I  am  not 
disused  to  agree  with  Trousseau  that  it  has  any  decided  periodicity, 
though  there  may  be  intervals  of  silence.  Hyperaesthesia  of  the  scalp, 
photophobia,  and  tenderness  of  the  muscles  at  different  parts  of  the  body 
are  usual  accompaniments.  Bertalot2  of  Pfeddersheim,  in  an  analysis  of 
24  cases,  has  found  photophobia  to  be  more  commonly  a  symptom  of  the 
later  stages,  in  which  conclusion  I  am  inclined  to  concur.  The  psychical 
symptoms  are  present  in  every  case,  though  delirium  is  not  so  common 
among  very  young  children,  and  when  it  does  occur  is  followed  by  a  state  of 
semi-consciousness,  and  finally  by  coma.  The  patients  will  not  speak, 
rebel  against  food  and  interference  of  any  kind,  and  after  a  time  it  is 
very  difficult  to  arouse  them.  One  very  interesting  fact  is  that  the 
coma  is  never  sudden,  but  is  preceded  in  every  instance  by  either  somno- 
lence or  delirium  of  the  muttering  variety.  The  coma  sometimes  becomes 
less  profound  in  character,  and  there  may  be  a  lucid  interval  before  death. 
Mot o rial  Disturbances — The  eyes  are  nearly  always  affected;  and  the 
ocular  trouble  is  either  strabismus,  ptosis,  or  a  pupillary  change.  The 
former  is  an  early  symptom,  and  is  probably  the  first  indication  of  para- 
lysis of  any  kind,  and  is  seen  most  perfectly  when  a  patient  is  awakened 

1  Lectures  upon  Clinical  Medicine,  Am.  edition,  vol.  i.  p.  877. 

2  Jahrbuch  Air  Kinderheilkunde,  B.  9,  H.  3. 


ACUTE    GRANULAR    MENINGITIS.  57 

or  aroused.  The  pupils  are  sometimes  unequally  dilated,  but  when  the 
coma  supervenes  dilatation  is  complete ;  pupillary  changes  are,  however, 
by  no  means  constant. 

Unilateral  paralysis  is  not  rare  ;  some  of  the  facial  muscles  being  alone 
affected,  or  there  may  be  extensive  hemiplegia,  which  is  an  advanced 
symptom.  Spastic  contractions  are  evidences  of  a  condition  of  central 
irritability;  and  rigid  flexion  of  the  muscles  of  the  thumb,  or  muscles  of 
the  sub-occipital  region,  are  examples  of  this  kind.  The  patient  com- 
monly lies  with  his  thumbs  drawn  into  the  palm  of  the  hand  and  covered 
by  the  fingers,  and  it  is  sometimes  difficult  to  open  the  hands. 

I  have  alluded  to  convulsions,  and  in  addition  may  say,  that  they  are 
more  prominent  in  the  first  four  days,  and  vary  in  severity  if  the  coma  be 
either,  very  deep  or  there  is  a  condition  of  semi-consciousness.  In  the 
latter  case  they  may  involve  isolated  groups  of  muscles. 

Ophthalmoscopic  Signs Bouchet,1  Galezowski,2  and  numerous  ob- 
servers have  called  attention  to  the  value  of  the  ophthalmoscope  as  an 
instrument  for  diagnosis  in  tubercular  meningitis.  The  latter  has  found 
two  forms  of  neuritis  as  evidences  of  this  disorder  ;  one  a  peri-neuritis, 
and  the  other  an  inflammation  of  the  optic  nerve  itself.  "Whiteness  about 
the  papilla,  deposits  of  granular  matter  in  the  choroid,  and  tortuosity  of 
the  retinal  vessels,  are  appearances  which  have  been  described  by  others. 
Frankel3  and  Steffen  found  tubercle  in  the  choroid  some  weeks  before  the 
invasion  of  the  disease ;  and  Broadbent,4  in  examining  the  fundus,  dis- 
covered that  the  optic  disks  were  dusky  red,  and  mottled  by  white  spots ; 
and  the  retinal  veins  were  enlarged,  while  the  arteries  were  very  small. 
Tubercular  meningitis  of  the  convexity  presents  no  Ophthalmoscopic  signs. 

ACUTE  GRANULAR  MENINGITIS  OF  THE  CONVEXITY. 

In  the  table  I  presented  when  speaking  of  the  basal  division  of  this  dis- 
ease, I  mentioned  the  prominent  symptoms  of  this  variety.  When  I  add 
that  delirium  and  other  decided  psychical  symptoms  are  highly  charac- 
teristic of  inflammation  of  the  vertical  region,  I  have  described  the  differ- 
ence between  the  two  forms.  This  variety  runs  its  course  in  a  much 
shorter  time,  death  generally  resulting  in  from  a  week  to  ten  days. 

When  the  malady  (either  basal  or  vertical)  occurs  in  conjunction  with 
certain  tubercular  affections  of  the  lungs  or  peritoneum,  there  are  local 
symptoms  which  precede  those  of  the  meningeal  disorder,  but  the  invasion 
of  the  disease  is  often  very  sudden.  Constipation,  followed  by  a  typhoid 
state  and  drowsiness,  are  the  precursors  of  meningitis  when  antecedent 

1  Du  Diagnostic  des  Maladies  du  Systfeme   nerveux  par  1' Ophthalmoscope. 
Paris,  1866. 

2  Arch.  G6n.,  1867,  vol.  ii.  p.  262. 

3  Virchow's  Jahresbericht,  1869,  p.  621. 

4  Trans,  of  London  Pathological  Society,  vol.  xxiii.  p.  216. 


58  DISEASES    OF    THE    CEREBRAL    MENINGES. 

lung  disease  has  existed.  Not  only  may  children  be  subject  to  this  dis- 
ease, but  adults  are  as  well ;  and  we  sometimes  find  it  as  a  sequence  of 
various  zymotic  diseases,  typhus  or  typhoid,  remittent  and  other  fevers,  as 
well  as  pulmonary  tuberculosis.  A  marked  elevation  of  the  evening  tem- 
perature, incomplete  hemiplegia,  vomiting,  or  convulsions,  are  the  promi- 
nent features  of  such  a  termination.  Strabismus,  unequal  mydriasis,  high 
pulse,  and  temperature,  with  some  of  the  other  symptoms  which  charac- 
terized the  disease  in  the  child,  that  have  already  been  described,  are 
generally  present. 

It  is  sometimes  so  insidious  in  its  approach  and  development  as  to  puz- 
zle the  observer.  The  phthisical  patient  may  become  listless,  drowsy,  or 
complain  of  headache.  He  often  wanders  and  gives  way  to  a  mild  form 
of  delirium,  which  appears  during  the  latter  part  of  the  day.  This  com- 
plication may  occur  during  the  early  stages  of  the  pulmonary  affection. 

Causes — The  question  of  diathesis  naturally  arises  before  any  other, 
and  we  are  immediately  puzzled,  for  on  one  side  we  find  that  Rokitansky, 
Robin,  Empis,  Clark,  and  others  consider  the  disease  hot  to  be  directly 
connected  with  the  tuberculous  diathesis,  and  they  go  so  far  as  to  question 
the  identity  of  the  granular  deposit  in  the  brain  with  tubercle;  while 
arrayed  against  them  are  Rilliet,  Barthez,  Grisolle,  and  a  host  of  others 
who  are  equally  positive  that  it  is  in  every  case  an  expression  of  tubercu- 
losis. Leaving  the  discussion,  which  is  by  no  means  settled,  as  the  nature 
of  the  deposit  needs  much  more  investigation  than  it  has  received,  we  may 
assume  that  the  affection  is  usually  associated  with  a  "scrofulous"  cache- 
xia;  that  it  appears  among  children  who  are  badly  nourished,  and  in  whom 
the  nervous  diathesis  is  well  developed.  That  exposure,  insufficient  food, 
and  various  exciting  causes,  such  as  dentition  and  over-study,  produce  it, 
no  one  will,  I  think,  deny.  In  some  instances — and  these  are  by  no 
means  few — it  is  impossible  to  find  any  hereditary  tuberculous  history. 
As  to  age,  we  may  consider  that  the  so-called  primary  tubercular  menin- 
gitis rarely  occurs  after  the  fourteenth  year,  and  it  is  probable  that  a  great 
many  of  such  cases  are  unattended  by  tubercle,  but  by  a  granular  deposit 
of  simple  character ;  and  primary  tubercular  meningitis  in  after  life  is,  I 
think,  a  genuine  tubercular  disease. 

Watson1  makes  the  statement  that  fifty  children  are  attacked  within 
the  first  five  months  of  life  to  every  one  after  that  time.  I  have  found 
it  to  be  more  common  after  the  first  year,  between  the  first  dentition  and 
the  fifth  year,  though  general  practitioners  who  see  more  of  these  cases 
undoubtedly  find  them  before  that  time.  In  large  cities  the  mortality 
is  undoubtedly  greatest  in  the  summer  months,  when  diarrhoeal  as  well 
as  other  diseases  and  high  temperature  are  conducive  to  its  development. 
In  the  year  1871,  in  the  city  of  New  York,  84  deaths  from  "tubercular 
meningitis"  (the  reported  exciting  cause  being  "teething")  are  recorded 
in  the  Health  Board  Reports,  and  the  greatest  number  were  found  be- 
tween the  sixth  and  fourteenth  years,  a  fact  which  seems  to  be  irre- 

1  Practice  of  Physic,  p.  270. 


ACUTE    GRANULAR    MENINGITIS. 


59 


concilable  with  the  statement  that  it  is  generally  connected  with  the  first 
dentition.1 

The  table  presented  below  demonstrates  that  males  are  much  more 
frequently  affected  than  females,  and  of  169  deaths  91  were  of  males  and 
78  of  females.  Bertalot,  already  referred  to,  found  that  of  his  24  cases 
fourteen  were  boys  and  ten  were  girls.  Two  cases  occurred  in  the  first 
year  of  life,  seven  in  the  second,  five  in  the  third,  three  in  the  fourth, 
three  in  the  twelfth,  and  one  each  in  the  fifth,  ninth,  tenth,  and  fourteenth 
years.  The  youngest  patient  was  ten  weeks  old.  Twenty-two  out  of  the 
twenty-four  were  attacked  between  November  and  the  end  of  June.  The 
children  were  all  more  or  less  delicate,  they  had  frequently  grown  up 
under  bad  hygienic  conditions,  and  were  generally  scrofulous  or  scrofulo- 
rachitic.  In  twelve  there  was  a  distinct  hereditary  predisposition  to 
tuberculosis ;  two  cases  supervened  upon  chronic  coxitis ;  one  upon  trau- 
matic erysipelas;  two  upon  pertussis;  one  upon  measles;  and  one  upon 
the  first  signs  of  dentition. 

Morbid  Anatomy  and  Pathology From  the  immense  mass  ot 

confused  testimony  before  us  (for  the  disease  has  been  described  by  nearly 
every  writer,  from  the  time  of  Hippocrates),  it  is  extremely  difficult  to 
say  whether  the  post-mortem  appearances  are  always  those  of  a  tuberculous 
character,  or  whether  the  granular  substance  is  non-tuberculous,  or  again 
whether  in  some  cases  there  is  tuberculous  deposit  and  in  others  simple 
granular  collections.  Paisley,  who,  Watson  says,  was  the  first  to  clearly 
describe  the  affection  without  saying  much  about  its  tuberculous  nature, 
has  given  us  a  very  admirable  collection  of  facts  bearing  upon  its  morbid 
anatomy. 

Gerhard,2  one  of  the  early  medical  writers  of  this  country,  says :  "  It 
was  not  known,  previously  to  the  researches  of  Dr.  Rufz  and  myself,  that 
the  tuberculous  character  of  the  disease  was  anything  but  a  mere  compli- 
cation." Guersent,  Dance,  Hennis,  Greene,  and  others  shared  in  Ger- 
hard's opinion,  that  tubercular  meningitis  was  a  "  strumous"  disease. 

Rufz3  collected  40  cases,  and  in  every  instance  there  was  complicating 
pulmonary  tuberculosis. 

1  An  inspection  of  the  table  prepared  by  Dr.  C.  P.  Russell,  in  the  Report  of  the 
Board  of  Health  of  the  City  of  New  York  for  1870,  will  enable  the  reader  to 
perceive  the  preponderance  of  mortality  before  the  second  year  of  life. 


Nativity. 

Color- 

Pm 

lor 

ed. 

1 

1 

2 

3 

4 

5 

10 

13 

20 

25 

L'. 

S. 

For'n. 

year. 

M. 

P. 

M 

F. 

M. 

F. 

*r 

V. 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

F     M. 

F. 

M. 

F. 

M. 

F. 

M. 

F. 

82 

76 

92.. 

;;  ) 

2S    17 

i!l 

14 

0 

8 

A 

4 

7 

7 

3      4 

4 

1 

Also  five  males  of  30,  one  of  50,  and  one  of  55;  this  cause  of  death  was  .62 
per  cent,  of  the  combined  cause. 

2  Dunglison's  Prac.  of  Med.,  vol.  ii.  p.  243. 

3  Quoted  by  Marshall  Hall,  p.  94. 


60  DISEASES    OF    THE    CEREBRAL    MENINGE8. 

FenwicW  tables  are  valuable  in  displaying  the  distribution  of  tubercle 
in  the  affection. 

In  one  of  these,  sixteen  cases  of  meningitis  occurring  in  tubercular 
patients  are  detailed  in  which  tubercle  was  found  in  the  lungs  and  other 
organs,  but  not  in  the  brain. 

In  these  cases,  of  which  ten  were  males  and  six  females,  there  was  tu- 
berculous dej>osit  in  the  lungs  in  every  instance,  and  in  some  of  them 
other  organs  were  affected.  Positively  nothing  like  tubercle  could  be 
found  in  the  brain,  but  this  organ  was  either  congested  or  anaemic.  The 
membranes  were  "  wet,"  and  the  ventricles  contained  fluid.  Four  cases 
were  under  ten  years  of  age  ;  three  between  ten  and  twenty,  and  three 
between  twenty  and  thirty ;  four  were  in  the  fourth  decade,  and  one  in 
the  fifth  and  sixth.  In  other  cases  brought  forward  by  him  of  general 
tuberculosis,  it  was  found  that  of  fifty-four  examined,  nearly  four-fifths  of 
the  number  were  below  twenty-five  years.  All  of  these  fifty-four  had 
tuberculous  deposits,  both  in  the  brain  and  other  organs. 

The  seat  of  the  granular  deposit  seems  to  be  chiefly  the  arachnoid  and 
pia  mater,  though  the  dura  mater  has  been  found  as  well  to  be  the  site  of 
granular  accumulation.  It  is  scattered  mostly  along  the  base  of  the  brain 
and  about  the  large  arteries,  where  it  may  be  found  to  consist  of  masses  of 
little  round  pearly  or  yellowish  bodies  which  may  be  almost  as  small  as 
grains  of  coarse  corn  meal.  The  meningeal  arteries  are  dotted  over  with 
these  granules,  and  when  the  arachnoid  is  raised  numerous  underlying 
miliary  granules  are  exposed. 

Fig.  10. 


Tuberculous  Matter  about  the  Vessel*.     (Cornil  and  Ranvier.) — A.  Tuberculous  deposit. 
B.  White  blood-corpiiHcles.     C.  Granular  contents  of  vessel. 

The  membranes  are  all  more  or  less  congested  and  dotted  with  opaque 
spots  or  patches.  The  cortex  is  hyperaemic  and  the  ventricles  distended 
by  fluid.  Their  ependyma  is  toughened  and  rough,  and  presents  a  granu- 
lar apj>earance  which  may  be  likened  to  that  of  a  piece  of  white  shark's 
skin. 

Softening  of  various   parts  of  the  brain,  the   nerve  trunks  and  optic 

1  St.  George's  Hosp.  Reports,  vol.  vii.  p.  35. 


ACUTE    GRANULAR    MENINGITIS.  61 

commissure  are  not  uncommon  evidences  of  the  violence  of  the  disease. 
Patches  of  false  membrane  which  contain  in  their  meshes  these  granular 
bodies  are  scattered  over  the  convexity  and  base,  and  render  the  removal 
of  the  brain  or  its  membranes  separately  a  somewhat  difficult  matter.  The 
lungs,  or  other  organs,  may  also  present  indications  of  tuberculous  matter. 

Rendu1  affirms  that  whenever  there  is  paralysis  of  permanent  form  there 
must  be  some  arterial  obliteration  from  fibrinous  exudation  and  consequent 
softening,  and  he  does  not  believe  that  scattered  granulations  or  ventricu- 
lar effusion  are  alone  sufficient  for  its  causation. 

It  is  rarely  possible  to  very  closely  localize  limited  deposit  before  death, 
but  occasionally  this  may  be  done. 

A  very  interesting  case  is  reported  by  Raymond  which  presented  seve- 
ral suggestive  points.  One  was  that  the  motor  centre  of  the  right  arm 
was  the  seat  of  granular  lesion,  and  that  there  was  paralysis  of  that  mem- 
ber. This,  then,  is  an  exception  to  the  rule  to  which  I  have  just  re- 
ferred. 

"  The  patient,  a  man  twenty-two  years  of  age,  was  admitted  into  the 
hospital  in  the  early  part  of  the  month  of  January  last,  and  then  presented 
obvious  symptoms  of  pulmonary  tuberculosis,  not,  however,  very  pro- 
nounced. The  affection,  indeed,  seemed  fib  be  progressing  slowly.  He 
was  thin,  pale,  coughed  a  good  deal,  and  was  a  little  feverish. 

"  On  January  28  he  began  to  complain  of  violent  pain  in  the  right  hy- 
pochondrium,  and  two  days  later  vomiting  came  on.  This  recurred  fre- 
quently, the  ejected  matter  having  a  greenish  color.  At  the  same  time 
he  suffered  from  severe  headache,  which  affected  chiefly  the  left  side  of 
the  head.  Fever  then  showed  itself,  the  temperature  rising  to  140°;  the 
pulmonary  lesions  developed  more  rapidly,  and  the  general  condition  be- 
came much  worse.  On  March  24  he  complained  of  great  pain  in  his 
right  arm,  which  seemed  to  be  very  heavy  ;  at  times  he  had  great  difficulty 
in  moving  it.  On  March  25  there  were  fresh  pains  in  the  arm,  and  motor 
paralysis  was  complete,  sensibility  being  retained.  In  the  evening,  with 
a  great  effort,  he  succeeded  in  raising  his  arm  to  his  head.  The  paralysis 
of  the  arm,  up  to  the  time  of  his  death,  presented  the  character  of  inter- 
mittence.  There  never  existed  any  trace  of  paralysis  in  the  right  leg  nor 
in  the  left  arm  or  leg.  Perhaps  there  was  a  slight  degree  of  loss  of  power 
in  the  bucco-labial  muscle  of  the  right  side,  and  a  slight  deviation  of  the 
tongue  to  the  left,  but  these  symptoms  were  a  little  doubtful.  In  the 
whole  case,  there  was  nothing  else  comparable  with  the  paralysis  of  the 
arm,  which  was  indisputable.  The  patient  died  on  April  4. 

"  At  the  necropsy,  far  advanced  tubercular  lesions  were  revealed  in  the 
right  lung,  and  the  membranes  of  the  brain  were  found  to  be  the  seat  of 
tubercular  granulations.  These  were  found  in  the  pia  mater  over  the 
right  lobe,  and  there  they  were  disseminated  along  the  parietal  branch  of 
the  Sylvian  fissure.  On  the  left  side,  in  addition  to  the  tubercular  granu- 
lations, there  existed  some  meningitis  with  purulent  deposits.  The  men- 
ingitis was,  if  it  may  be  so  said,  circumscribed  and  localized  on  two  con- 
volutions, the  anterior  and  posterior  marginal  near  the  paracentral  lobe. 

1  Review  in  Gaz.  des  H6pitaux,  Jan.  15,  1873. 


62  DISEASES    OP    THE    CEREBRAL    MENINGES. 

There  the  tubercular  granulations  were  very  numerous,  and  formed  a  sort 
of  tumor.  The  piu  muter,  covered  with  pus,  adhered  closely  to  the  sub- 
jacent cerebral  tissue.  In  other  parts,  where  there  were  granulations, 
there  was  no  vestige  of  meningitis.  No  other  cerebral  lesions,  foci  of 
softening,  or  obliteration  of  capillaries,  could  be  discovered.  There  was 
a  small  amount  of  fluid  in  the  ventricles,  but  nothing  to  note  in  the  spinal 
cord  or  nerves  of  the  arm. 

"  Such  are  the  facts  of  this  case,  which  may  be  summed  up  as  follows  : 
Motor  paralysis  of  the  right  arm,  somewhat  intermittent  in  the  sense  that 
it  was  at  times  complete,  and  at  other  times  less  absolute  ;  and  to  explain 
this  paralysis  no  other  lesion  than  the  tubercular  meningitis  in  the  region 
of  the  motor  centre  of  the  arm."1 

Prognosis No  inflammatory  disease  of  the  brain  or  its  membranes 

is  more  serious  or  rapidly  fatal  than  is  this.  The  termination  is  in  death  in 
from  two  to  three  weeks,  though  very  rarely  recovery  may  take  place  be- 
fore the  disease  has  gone  beyond  the  period  of  invasion.  The  ophthal- 
moscope is  our  best  friend  at  this  time.  If  there  be  optic  neuritis,  and 
basilar  meningitis  is  suspected,  there  is  very  little  comfort  to  be  derived 
from  such  an  examination.  If  the  child  recover,  it  will  be  with  impaired 
intellect,  epilepsy,  or  some  other  serious  life-long  trouble. 

An  anonymous  writer  in  the  Gazette  Medicale  upon  the  treatment  of 
tubercular  meningitis,  says  that,  in  a  practice  of  thirty  years,  he  has  seen 
'between  eighty  and  ninety  cases,  and  during  that  time  there  were  but  two 
recoveries.2  Bierbaum*  has  reported  three  recoveries. 

Diagnosis. — This  disease  may  be  mistaken  at  different  stages  for 
several  other  acute  conditions,  viz. : — 

A.  Typhoid  fever — typhus  fever. 

B.  Scarlet  fever  or  smallpox. 

C.  Pleurisy  or  pneumonia. 

D.  Eccentric  irritation,  such  as  that  produced  by  worms,  etc. 

E.  Other  forms  of  meningitis. 

F.  Exhaustion. 

A.  Typhoid,  in  some  of  its  forms,  or  typho-pneumonia,  may  resemble 
ftubercular  meningitis,  either  of  the  primary  or  secondary  forms.  This  is 
especially  the  case  when  typhoid  symptoms  are  added  to  those  of  phthisis. 
The  irregular  varieties  of  typhoid  are  attended  by  absence  of  diarrhoea, 
tympanites,  and  other  abdominal  symptoms.  The  eruption  of  typhoid  may 
also  resemble  the  tache  ce're'brale  of  this  form  of  menin<ntis,  but  it  is 

O  ' 

usually  confined  to  the  chest  and  abdomen,  and  is  an  early  symptom. 
Typho-pneumonia  may  bear  a  close  resemblance  to  secondary  tubercular 
meningitis,  and  this  is  particularly  the  case  if  moist  rales  can  be  heard  all 
over  the  chest,  and  there  is  some  dulness  at  the  apex.  Certain  points  are 

1  London  Mod.  Record,  July  15,  1876.     Abstract  from  Lc  Progres  M6dicul, 
April  22,  1870. 

2  Gazette  Medicale,  1871,  412. 

3  Deutsche  Klinik,  1873,  184. 


ACUTE    GRANULAR    MENINGITIS.  63 

to  be  borne  in  mind,  however,  that  will  put  the  diagnostician  on  his  guard. 
Uncomplicated  typhoid  is  a  disease  of  longer  duration,  and  the  abdominal 
symptoms  are  usually  marked.  There  is  tenderness  in  the  left  iliac  fossa, 
high  evening  temperature,  nose-bleed,  and  usually  slight  head  symptoms, 
which  vary.  The  eruption  fades  away  under  pressure,  instead  of  being 
produced  by  pressure  or  contact,  as  is  the  case  in  the  meningeal  difficulty. 
The  prodromal  symptoms  of  typhoid  are  not  nearly  so  marked  as  those  of 
the  other  disease. 

Typhus  fever  may  sometimes  make  the  diagnosis  exceedingly  difficult; 
for,  as  we  know,  its  duration  is  about  that  of  the  tubercular  trouble,  and 
head  symptoms  are  its  marked  feature.  The  general  absence  of  pulmo- 
nary symptoms,  the  appearance  of  the  dark  rash,  and  the  antecedents  of 
the  patient  offer  us  guides. 

B.  Scarlet  fever,  which  sometimes  begins  with  vomiting  and  early  head 
symptoms,  puzzles  the  observer.  The  throat  trouble,  the  early  appear- 
ance of  the  eruption,  the  peculiar  "  strawberry  tongue"  which,  as  far  as  I 
am  aware,  is  found  in  but  two  diseases,  diphtheria  and  scarlet  fever,  and 
the  high  and  continued  elevation  of  temperature  during  the  eruption,  are 
sufficient  to  put  the  medical  man  upon  the  alert. 

Smallpox,  without  the  eruption,  may  sometimes  mislead  us.  The  pro- 
dromal symptoms,  pain  in  the  back,  vomiting,  and  headache  are  different 
from  the  same  symptoms  in  tubercular  meningitis.  They  are  more  severe, 
and  may  immediately  usher  in  coma.  Bleeding  from  the  nose  and  mouth 
I  have  witnessed  in  three  patients.  This  form  of  smallpox  is  quite  rare. 
In  the  course  of  six  years,  during  which  I  have  been  connected  with  the 
Health  Department  of  the  City  of  New  York,  I  have  seen  over  one 
thousand  cases  of  the  disease,  and  I  do  not  remember  having  encoun- 
tered but  ten  or  twelve  cases  of  this  terrible  form  of  variola.  These  cases 
were  all  adults.  If  pronounced  smallpox  should  suggest  the  other  affec- 
tion, it  will  be  found  that  in  two  or  three  days  any  blush  eruption  (which 
could  hardly  be  mistaken  for  the  maculae  of  tubercular  meningitis,  which 
is  a  late  symptom)  will  develop  so  that  the  characteristic  vesicles  may  be 
seen.  In  both  scarlet  fever  and  smallpox  the  history  of  exposure  often 
supplies  the  link. 

(7.  Pneumonia  and  pleurisy  can  only  be  mistaken  when  we  neglect  to 
take  into  account  the  chill,  pain  in  the  side,  and  physical  signs.  The 
latter  disease  may  sometimes  be  supposed  to  exist ;  for  Gee  has  heard  the 
friction  sound  of  pleurisy  in  tubercular  meningitis. 

D.  Reflex  irritation  from  ascarides  may  produce  many  of  the  early 
symptoms  which  also  indicate  tubercular  meningitis,  and  even  convulsions 
may  appear ;  but,  unlike  the  tubercular  disease,  there  is  no  further  pro- 
gress.    The  use  of  an  anthelmintic  will  clear  up  the  diagnosis,  if  we  have 
reason  to  suspect  these  parasites. 

E.  From  simple  meningitis  we  may  distinguish  the  disease  chiefly  by 
the  late  appearance  of  the  delirium.     The  patient  lapses  into  unconscious- 
ness in  the  former  disease  in  two  or  three  days,  while  in  tubercular  menin- 


64  DISEASES    OF    THE    CEREBRAL    MENINGES. 

gitis  the  acute  mental  disturbance  is  not  so  immediate.     Acute  meningitis 
runs  its  course  usually  in  a  week. 

Various  intracranial  diseases  may  resemble  at  different  times  the  disease 
under  consideration  ;  but  as  I  propose  to  treat  of  these  hereafter,  it  will  be 
well  to  omit  them  here. 

F.  Exhaustion The  excitement  that  has  been  lately  aroused  in  Mi  in- 
land by  the  Penge  case  gives  this  part  of  the  subject  decided  importance. 
It  will  be  remembered  that  one  Louis  Staunton,  with  two  accomplices,  one 
of  whom  was  his  brother,  and  the  other  a  woman  with  whom  he  was  living 
upon  terms  of  criminal  intimacy,  starved  to  death  his  wife,  and  that  they  all 
narrowly  escaped  capital  punishment  or  transportation.  The  coroner's  jury 
decided  that  the  real  cause  of  her  death  was  starvation,  while  several  dis- 
tinguished medical  men  contended  that  she  had  died  from  tubercular  menin- 
gitis, but  did  not  deny  that  she  had  been  neglected.  The  disputed  points 
seemed  to  be,  the  rapid  emaciation  and  great  anaemia  of  the  tissues,  as  well 
as  disappearance  of  subcutaneous  fat.  Her  symptoms  before  death  were 
drowsiness,  passing  into  coma,  stertor,  rigidity  of  one  arm,  and  inequality 
of  pupils.  These  symptoms  appeared  but  shortly  before  death,  and  were 
supposed  by  Dr.  Greenfield,1  who  made  a  most  sensible  and  convincing 
communication  to  the  Lancet,  not  to  account  for  starvation  alone,  but  to  be 
probably  due  to  tubercular  meningitis. 

Opposed  to  him  are  several  observers  (among  them  Virchow,  who  re- 
viewed the  English  testimony),  who  held  that  the  great  emaciation,  loss 
of  weight  of  the  internal  organs,  emptiness  of  the  cavities  of  the  heart,  and 
certain  forms  of  congestion  were  clearly  indicative  of  starvation.  Green- 
field proves,  I  think,  that  none  of  these  appearances  were  sufficient  in 
themselves  for  us  to  say  definitely  that  they  were  due  to  starvation  ;  that 
they  may  often  be  a  result  of  exhausting  disease;  that  the  congestion  wit- 
nessed was  an  ordinary  post-mortem  appearance ;  and  finally  that  tubercle 
existed  in  the  lungs  and  brain ;  while  in  the  latter  there  were  found  pri- 
mary indications  of  softening  as  well  as  adhesion  of  the  meninges. 

Gee  calls  attention  to  forms  of  wasting  disease  with  profound  emaciation 
which  may  closely  simulate  tubercular  meningitis,  but  are  connected  with 
digestive  derangements  and  malnutrition;  and  Sir  Wm.  Gull,  in  one  of 
the  English  hospital  reports,  brought  forward  several  cases  of  hysterical 
anorexia;  and  in  the  profound  form  of  cerebral  anaemia  there  can  be  symp- 
toms which  may  resemble  some  of  those  expressed  in  tubercular  meningitis 
so  greatly,  as  to  possibly  lead  to  an  error  in  diagnosis. 

Treatment — More  can  be  done  for  the  patient  in  the  early  stages 
than  at  any  other  time.  Cod-liver  oil,  phosphorus  (F.  37),  a  nitrogenous 
diet,  and  preparations  of  iodine  are  all  of  great  service.  The  syrup  of  the 
iodide  of  iron  (F.  42)  is  an  excellent  remedy  in  the  earliest  stage,  if  we 
recognize  the  significance  of  the  somewhat  irregular  group  of  symptoms. 
The  iodide  of  potassium  has  been  by  many  used  during  later  stages. 

1  London  Lancet,  Oct.  G,  1877. 


CHRONIC    CEREBRAL    MENINGITIS.  65 

Fleming1  reports  a  cure  in  the  case  of  a  girl  two  and  a  half  years  old  by 
large  doses  of  the  iodide,  and  the  experience  of  others  is  also  encouraging. 
Cold  to  the  head  and  the  bromides  in  the  later  stages  are  of  greater  benefit 
than  any  other  remedies.  Ergot  has  been  successfully  used  by  Gibney  in 
one  case  of  so-called  tubercular  meningitis.  It  should  be  administered  in 
full  doses  often  repeated.  Gee  recommends  closure  of  the  eyelids  by  ad- 
hesive plaster,  should  there  be  any  ulceration  of  the  cornea.  Blistering, 
bleeding,  and  violent  treatment  of  any  kind  are  to  be  strongly  condemned  ; 
quiet  and  darkness  should  be  insisted  upon  as  early  as  possible,  and  over- 
solicitous  friends  should  be  excluded  from  the  sick-room.  Food  of  a  liquid 
form  may  be  given  by  enemata,  or  by  the  mouth,  using  a  syringe,  and 
being  careful  in  introducing  its  point  between  the  teeth. 


CHRONIC  CEREBRAL  MENINGITIS. 

This  very  rare  disease,  which  may  be  either  the  result  of  acute  menin- 
gitis, or  develop  idiopathically,  or  after  head  injury,  is  of  slow  appearance 
and  progress,  and  resembles  several  organic  diseases  of  the  braiu  proper, 
among  them  softening,  general  paralysis,  and  brain  tumors. 

Symptoms. — One  of  the  early  symptoms,  especially  of  the  vertical 
variety,  is  headache,  which  varies  in  severity.  It  is  of  a  dull  character, 
and  is  seated  in  the  top  of  the  head,  and  is  increased  by  any  effort  which 
augments  the  cerebral  blood  pressure.  In  certain  cases  there  is  loss  of 
memory,  and  other  mental  symptoms,  which  resemble  closely  those  of 
general  paralysis  of  the  insane  ;  and  this  mental  impairment  may  terminate 
in  dementia.  The  vertical  form  is  generally  complicated  with  encepha- 
litis and  muscular  paralysis,  as  well  as  spasms  and  twitchings  of  either  a 
limited  group  of  muscles,  or  the  arm  and  leg  of  one  side.  Tremor  and 
sometimes  convulsions  occur  after  a  short  period,  while  after  the  involve- 
ment of  the  cortical  substance  we  may  have  marked  motorial  symptoms, 
such  as  paralysis  with  contractures,  and  paralysis  of  the  bladder  or  sphinc- 
ters, both  of  the  bladder  and  rectum,  so  that  the  patient'passes  his  urine 
and  feces  in  an  involuntary  manner.  The  disease  is  generally  progressive, 
and  there  is  an  increase  in  the  number  of  convulsions.  The  mental  decay 
advances  rapidly,  and  the  patient  finally  dies,  at  the  end  of  a  few  months, 
in  a  comatose  state.  The  basilar  form  of  disease  is  much  more  interesting 
than  that  of  which  I  have  just  spoken,  the  cranial  nerves  being  more  or 
less  involved  ;  and  symptoms  of  cranial  paralysis  of  a  progressive  character 
form  a  distinguishing  feature  of  the  disease.  Thus,  in  thirteen  cases  col- 
lected by  Dr.  Cross,2  of  this  city,  the  third  nerve  was  paralyzed  generally 
on  the  left  side  in  nine  instances,  and  in  one  case  the  third  pair  on  both 
sides  was  affected.  In  nine  of  these  cases  strabismus  was  noted  ;  in  five 
of  which  it  was  external  and  existed  on  the  left  side.  The  pupils  were 

1  British  Med.  Journal,  1871,  p.  443. 

2  Psychological  and  Medico-Legal  Journal,  New  Series,  vol.  ii.  p.  220. 

5 


66  DISEASES    OF    THE    CEREBRAL    MENINGES. 

dilated  in  eight  instances,  and  contracted  once.  Obscureness  of  vision 
was  observed  to  be  prominent  in  four  cases,  while  ptosis  existed  in  five, 
occurring  once  on  both  sides.  Double  vision  was  present  in  many  cases. 
Blindness  occurred  once  in  the  left  eye,  which  was  the  result  of  suppura- 
tive  choroiditis.  In  another  instance  there  was  loss  of  sight  in  both  eyes. 
I  may  select  four  of  Dr.  Cross's  cases,  which  represent  very  fully  the 
course  of  the  disease  : — 

CASE  I A  young  man  came  to  the  clinic  who  was  affected  with 

external  strabismus,  ptosis,  and  dilatation  of  the  pupil  of  the  left 
eye.  lie  had  a  most  intensely  agonizing  pain  in  the  head,  vertigo, 
frequent  attacks  of  vomiting,  and  paresis,  if  not  paralysis,  of  the  arm  and 
leg  on  the  same  side.  He  was  treated  with  mercury  and  large  doses  of 
the  iodide  of  potassium.  In  a  short  time  the  pain  in  his  head  disappeared, 
and  sifter  the  lapse  of  a  few  weeks  the  paralysis  was  cured.  Two  or  three 
months  subsequently  he  reappeared,  with  a  corresponding  set  of  symptoms 
in  the  right  eye,  and  the  right  half  of  the  body,  and  with  pain  in  his 
head  as  severe  as  during  the  previous  attack.  He  was  again  treated  with 
mercury  and  the  iodide  of  potassium,  when  his  symptoms  again  disap- 
peared, and  have  not  since  returned.  In  this  case  there  was  some  slight 
suspicion  of  syphilis. 

CASE  II — A  man,  twenty-eight  years  of  age,  came  under  my  charge 
some  two  years  ago.  At  that  time  he  was  suffering  from  pain  in  the 
head,  vertigo,  dilatation  of  the  pupil,  external  strabismus,  double  vision, 
numbness,  and  slight  paralysis  of  the  opposite  side  of  the  body.  As  far 
as  I  was  able  to  discern,  the  ocular  paralysis  was  confined  solely  to  the 
left  internal  rectus  muscle.  Until  within  a  few  months  prior  to  his  com- 
ing under  my  observation,  he  had  apparently  enjoyed  excellent  health, 
with  the  exception  of  a  severe  headache,  from  which  he  had  suffered  quite 
acutely.  He  stated  that  the  disease  with  which  he  was  afflicted  had  come 
on  slowly,  and  gradually  increased  in  degree.  He  acknowledged  that  he 
had  had  a  hard  chancre  several  years  previously. 

Under  the  influence  of  large  doses  of  the  iodide  of  potassium,  the  symp- 
toms rapidly  disappeared,  and  he  has  since  had  no  return  of  the  paralysis, 
although  he  afterwards  experienced  severe  headache,  which  disappeared 
under  treatment.  I  examined  his  retinae,  but  found  no  disease. 

CASE  III — Shortly  after  this  I  was  consulted  in  regard  to  the  case  of 
a  gentleman,  thirty-five  years  old,  who  was  suffering  apparently  from 
symptoms  similar  to  those  observed  in  the  preceding  case,  with  the  excep- 
tion of  the  paresis  of  the  extremities.  He  had  well-marked  head-symp- 
toms and  numbness,  which  was  limited  to  one  side  of  the  body,  but  the 
paralysis  was  confined  exclusively  to  the  ocular  muscles.  His  eyes  had 
been  carefully  examined  by  an  eminent  ophthalmic  surgeon,  who  had 
informed  him  that  they  were  healthy,  and  that  his  trouble  was  probably 
cerebral.  He  was  a  very  robust  man,  and  had  apparently  suffered  from 
no  severe  disease  until  the  beginning  of  his  present  trouble.  On  question- 
ing him  closely,  he  stated  that  he  had  had  syphilis  twelve  years  ago,  for 
which  lie  had  been  carefully  treated,  and  consequently  considered  himself 
cured.  When  I  first  saw  him,  the  double  vision  had  existed  several 
months,  and  during  that  time  had  been  almost  constantly  present.  I  did 
not  treat  this  patient,  and  consequently  do  not  know  the  result. 

CASE  IV — A  married  gentleman,  forty-one  years  of  age,  came  under 
my  care  in  1873.  He  was  descended  from  a  family  saturated  with  rheu- 


CHRONIC    CEREBRAL    MENINGITIS.  67 

matism  and  gout,  and  five  of  whom  had  died  of  paralysis.  At  this  time 
he  was  suffering  from  myalgia,  which  I  found  to  be  located  in  the  muscles 
of  the  chest  and  back.  This  condition  lasted  about  three  months,  and 
then  disappeared  under  treatment.  He  stated  that  prior  to  this  time  his 
health  had  been  good.  He  had  been  temperate  in  his  habits,  and  had 
never  had  acute  articular  rheumatism,  gout,  nor  syphilis.  In  July,  1873, 
he  first  observed  that  the  pupil  of  the  right  eye  was  much  contracted. 
This  was  followed  by  headache,  vertigo,  and  obscureness  of  vision.  In 
December  he  came  to  my  office  and  informed  me  that  his  ocular  troubles 
had  increased.  At  that  time  his  condition  was  as  follows :  He  had  a  dull, 
heavy  pain  behind  the  ears,  which  seemed  to  extend  along  the  base  of 
the  brain,  and  was  at  times  throbbing  in  character.  There  was  vertigo 
and  indistinctness  of  vision,  which  he  described  as  a  blurring  of  objects ; 
his  right  pupil  was  extremely  contracted,  and  did  not  respond  to  the 
stimulus  of  light.  Far  and  near  objects  were  very  indistinct,  and  appeared 
to  be  one  above  the  other.  When  he  looked  at  the  pavement  it  appeared 
to  be  raised  above  its  natural  position.  There  were  double  vision  and 
strabismus. 

He  kept  his  head  constantly  turned  to  the  right  and  downwards,  in 
order  to  bring  the  axes  of  his  eyes  parallel.  All  his  organs  were  healthy, 
with  the  exception  of  his  brain.  There  was  apparently  partial  paralysis 
of  the  right  internal  rectus  and  right  inferior  oblique  muscles.  This  gen- 
tleman was,  by  my  advice,  carefully  examined  by  two  eminent  ophthalmic 
surgeons  of  this  city,  both  of  whom  were  of  the  opinion  that  there  was  no 
disease  of  the  eyes.  An  important  point  in  this  connection  is  the  fact 
that  this  patient  had  been  in  the  habit  of  using  a  magnifying  glass  with 
the  affected  eye  to  examine  the  delicate  parts  of  machinery,  in  order  to 
see  that  they  were  properly  constructed;  and  this  operation  was  con- 
ducted in  a  dark  room,  lasting  several  hours  daily.  I  carefully  examined 
this  patient's  spinal  cord  (as  I  always  do  in  all  these  cases),  but 
found  no  indications  whatever  of  spinal  disease.  I  ordered  him  to  take 
the  iodide  of  potassium,  in  fifteen-grain  doses,  three  times  a  day,  well 
diluted  in  water,  and  to  rapidly  increase  the  amount;  but  the  first  dose 
caused  him  such  intense  nausea  and  vomiting  that  he  could  not  be  induced 
to  take  it  subsequently.  He  consequently  ceased  taking  any  medicine, 
and  for  some  time  he  continued  to  grow  worse,  all  his  symptoms  increasing 
in  severity.  He  was  obliged  to  give  up  his  business,  and  has  since  passed 
most  of  his  time  in  out-door  exercise. 

The  pupil  of  the  right  eye  remained  permanently  contracted  for  several 
months.  A  short  time  since  I  met  him,  and  he  told  me  that  he  was  about 
to  resume  his  business,  he  had  so  nearly  recovered.  His  pupil  was  still 
contracted,  but  not  to  the  same  degree  that  it  was  when  he  first  came 
under  my  care  a  year  ago.  He  now  holds  his  head  straight ;  there  is  no 
apparent  strabismus,  although  his  wife  informs  me  that  he  occasionally 
sees  double.  His  headache  and  vertigo  have  disappeared.  The  only 
medicines  that  he  has  taken  during  this  period  have  been  tonics  and  out- 
door exercise.  I  made  particular  inquiry  in  this  case,  in  order  to  discover, 
if  possible,  a  constitutional  cause,  but  I  was  fully  satisfied  that  none 
existed. 

Convulsions  of  a  severe  character  are  an  alarming  feature  of  the  dis- 
ease when  the  base  of  the  brain  is  affected.  Both  of  these  forms  of 


68  DISEASES    OF    THE    CEREBRAL    MENINGE8. 

meningitis  may  be  connected  with  cerebral  growths  and  syphilitic  and 
tuberculous  deposits. 

Causes Males  seem  to  be  oftener  affected  than  females,  and  the 

disease  is  ordinarily  one  of  adult  life.  It  is  connected  oftentimes  with  the 
tuberculous  diathesis,  and  is  not  rarely  dependent  upon  constitutional 
syphilis;  it  may  be  seemingly  idiopathic,  or  result  from  head  injury,  •  \- 
posure  to  the  sun,  intemperance,  the  acute  zymotic  fevers,  and  the  other 
causes  of  meningitis. 

Morbid  Anatomy  and  Pathology — The  cerebral  meninges  have 
been  found  to  be  thickened,  adherent  to  each  other,  or  to  the  inner  surface 
of  the  cranial  bones,  with  effusions  beneath,  which  have  undergone  partial 
organization  ;  sometimes  gummy  exudation  of  syphilitic  origin  will  be 
found  scattered  over  the  surface  of  the  brain,  or  calcareous  plates  of  per- 
haps an  inch  in  diameter  will  be  found  in  the  dura  mater,  such  as  I  have 
already  spoken  of  in  chronic  pachymeningitis.  If  the  disease  has  involved 
the  cortical  substance  of  the  brain,  we  may  discover  patches  of  softening 
of  variable  extent  and  depth,  and  perhaps  superficial  abscesses.  At  the 
base  of  the  brain  the  meningitis  is  not  generally  so  diffuse,  but  occurs  in 
circumscribed  spots,  the  cranial  nerve  trunks  being  generally  softened  and 
bound  down  by  bands  of  new  tissue. 

Diagnosis — The  form  of  meningitis  of  the  convexity  presents  so 
many  symptoms  that  are  common  to  other  brain  diseases,  that  the  matter 
of  diagnosis  is  often  very  difficult,  and  it  is  impossible  at  times  to  deter- 
mine the  nature  of  the  patient's  disease  until  after  death.  Meningitis  of 
the  base,  however,  is  much  more  easily  diagnosed.  There  are  nearly 
always  ophthalmoscopic  appearances,  which  is  not  the  case  in  the  other 
form  of  disease,  and  some  one,  or  all  of  the  cranial  nerves  are  paralyzed. 
The  symptoms  of  tumor  may  counterfeit  those  of  chronic  basilar  menin- 
gitis, but  perhaps  are  more  severe.  If  the  disease  be  of  a  syphilitic  char- 
acter, the  question  of  diagnosis  is  a  puzzling  one ;  for  in  some  respects 
a  condition  which  favors  the  formation  of  syphilitic  tumor  and  chronic 
meningitis  is  the  same,  and  occasionally  these  two  diseases  are  found  to 
coexist. 

Prognosis — Should  the  disease  be  syphilitic,  the  prognosis  is  nearly 
always  favorable,  but,  if  it  be  the  result  of  injury,  recovery  ia  less  likely 
to  take  place ;  should  it  follow  the  acute  exanthematous  fevers,  there  is  very 
little  hope. 

Treatment — Our  main  reliance  is  in  the  free  use  of  large  doses  of 
iodide  of  potassium,  or  in  the  employment  of  mercurials.  Active  counter- 
irritation  and  the  use  of  blisters  and  cauterization  may  afford  a  great  deal 
of  relief.  A  saturated  solution  of  the  iodide  of  potassium  may  be  ordered, 
and  the  patient  should  be  directed  to  begin  with  a  dose  of  ten  drops  three 
times  a  day,  and  gradually  increase  one  drop  with  each  dose  until  he  takes 
a  hundred  drops  or  more  during  the  twenty-four  hours. 


CEREBRAL    HYPER^EMIA.  69 


CHAPTER    II. 

DISEASES  OF  THE  CEREBRUM  AND  CEREBELLUM. 

CEREBRAL  HYPER^EMIA. 

Synonyms — Cerebral  congestion.  Hypere'mie  ce"re*brale  (FrJ).  Hy- 
peramie  des  Gehirns  (6rer.). 

Definition — A  condition  characterized  by  an  abnormal  increase  in 
the  amount  of  blood  contained  in  the  cerebral  vessels,  and  expressed  by 
symptoms  which  indicate  pressure,  and  irritation  of  the  cerebral  nerve- 
cells.  Before  entering  into  the  discussion  of  this  affection,  I  desire  to 
state  that  in  very  few  cases  do  I  consider  cerebral  hyperaemia  to  be  a 
distinct  cerebral  disease,  but  rather  one  form  of  expression  of  some  gene- 
ral condition.  The  apoplectiform  variety  described  by  Hammond  and 
Trousseau  is,  in  my  opinion,  generally  a  slight  cerebral  hemorrhage  ;  but  I 
shall  speak  of  it  under  this  heading,  for  the  reason  that  it  is  so  commonly 
a  result  of  acute  congestion,  while  the  striking  feature  of  "  cerebral  hem- 
orrhage" ordinarily  is  the  degenerated  arterial  state. 

Two  forms  of  cerebral  hypersemia  have  been  recognized  by  the  majority 
of  medical  writers,  one  of  them  which  is  active  and  connected  with  forci- 
ble arterial  fluxion,  and  the  other  passive,  and  the  result  of  some  impedi- 
ment to  the  venous  return.  I  prefer  to  adopt  the  terms  sthenic  and  asthenic, 
as  these  expressions  denote  pathological  conditions  much  more  appropri- 
ately than  do  those  in  common  use.  Either  may  exist  in  a  modified  de- 
gree as  physiological  states,  and  it  is  often  difficult  to  make  the  distinction 
between  a  normal  process  and  a  diseased  condition  ;  but  when  the  cerebral 
fulness  is  constant  or  increased  to  a  serious  extent,  we  may  safely  judge 
the  condition  to  be  pathological.  The  division  of  the  disease  expressed 
by  the  terms  I  have  just  mentioned,  though  adopted  by  most  of  the  au- 
thorities on  nervous  diseases,  is  for  some  reasons  unnecessary. 

Both  varieties  may  lead  to  accidents  symptomatized  by  attacks  of  coma, 
accessions  of  convulsion,  a  low  grade  of  paralysis,  mental  excitement,  and 
other  serious  results.  These  differ  only  in  their  manner  of  appearance. 
In  one,  they  are  early  and  sthenic  expressions,  and  are  produced  by  rapidly 
exerted  and  violent  force ;  and  in  the  other  their  advent  is  more  slow,  as 
they  appear  to  be  produced  by  a  sluggish  force  or  tardy  impairment  of 
cell  function,  though  sudden  accidents  which  embarrass  the  venous  return 
may  make  their  appearance  as  immediately  as  those  of  the  first  variety. 
Stupor  is  more  decidedly  characteristic  of  the  passive  or  asthenic  variety, 
than  that  in  which  rapid  dynamic  arterial  action  takes  place.  In  this,  the 
second  variety,  there  seems  to  be  a  dilatation  of  the  small  vessels,  a 


70  DISEASES    OP    THE    CEREBRUM    AND    CEREBELLUM. 

crowding  out  the  perivasculaf  fluid,  and  consequent  pressure  of  the  per- 
manently distended  vessels  upon  the  hyaline  membrane  next  to  the  cells, 
thus  preventing  the  removal  of  their  effete  material  and  consequently  im- 
pairing their  normal  action. 

Symptoms The  symptoms  of  this  condition,  as  I  have  stated,  may 

vary  from  evidences  of  what  seems  to  be  but  healthy  physiological  function 
to  those  which  are  unmistakably  grave  pathological  conditions ;  from  sim- 
ple throbbing  of  the  temporal  vessels  and  flushing  of  the  face,  to  coma, 
convulsions,  or  mania. 

Generally  the  symptoms  are  not  serious,  and  out  of  the  many  cases  I 
have  seen  (and,  by  the  way,  a  large  number  of  these  mild  cases  are  met 
with  in  private  practice)  they  are  of  a  type  which  may  be  recognized 
at  once.  The  patient  calls  attention  to  the  following  troubles  :  A  sense  of 
head-fulness  with  throbbing  of  the  temporal  arteries.  He  may  inform  us 
that  his  "  head  seems  to  be  of  unnatural  size  and  great  weight ;  that  he 
feels  as  if  the  skin  covering  the  head  is  much  too  tight."  He  complains 
of  tinnitus  aurium,  and  is  troubled  by  subjective  sounds  which  he 
compares  to  the  buzzing  of  bees,  the  ringing  of  bells,  and  the  rushing  of 
waters. 

There  seems  to  be  an  extraordinary  acuteness  of  all  the  senses.  He 
may  complain  of  muscce  volitantes,  and  inform  us  that  there  are  bright 
specks  or  motes  which  flit  across  the  field  of  vision.  He  may  say  that 
bright  light  is  painful,  and  complain  of  his  inability  to  read  fine  print,  be- 
cause the  letters  seem  to  dance  upon  the  page,  and  the  words  appear  hazy 
and  blurred.  Dtplopia  and  other  visual  troubles  may  annoy  him.  Sharp 
noises,  harsh  voices,  and  monotonous  sounds  seem  to  produce  distress  and 
discomfort.  He  may  have  hallucinations,  but  is  generally  able  to  appre- 
ciate their  unsubstantial  character.  He  arises  in  the  morning  unrefreshed 
and  uncomfortable,  complaining  of  muscular  weariness,  but  feels  better 
towards  the  middle  of  the  day.  After  his  dinner,  particularly  if  it  has 
been  a  hearty  one,  the  cerebral  condition  is  aggravated.  At  night  he 
finds  it  impossible  to  sleep,  and  he  tosses  to  and  fro,  his  head  being  hot 
and  his  extremities  cold.  The  mind  of  the  patient  is  preternaturally 
active,  and  his  brain  seems  filled  with  excited  fancies,  and  troubled 
thoughts — and  at  last  he  sleeps.  This  sleep,  however,  is  not  sound  ; 
dreams  of  all  kinds,  or  nightmare,  keep  him  in  a  state  of  wretched  semi- 
consciousness  till  the  morning  comes  to  find  him  utterly  used  up.  With 
the  patient,  mental  exertion  is  irksome,  and  study  or  concentration  is 
disagreeable  or  impossible.  There  is  headache  or  impaired  memory, 
thickness  of  speech,  and  various  difficulties  of  articulation.  He  may 
substitute  one  word  for  another,  even  though  it  be  one  in  common  use 
and  exceedingly  familiar. 

The  emotions  are  generally  disturbed  and  altered.  Irritability,  nervous 
excitement,  and  morbid  exhilaration  of  spirits  may  make  his  conduct 
strange  and  unnatural  to  those  about  him  ;  while  slight  things  seem  to  dis- 
turb and  harass  him.  The  attentions  of  friends,  though  they  may  be  of 
the  most  considerate  nature,  are  met  with  explosions  of  temper,  and  the 


CEREBRAL    HYPER^EMIA.  71 

patient  avoids  them  and  prefers  solitude.  Sometimes  he  takes  violent 
exercise  until  completely  exhausted,  when  wearied  Nature  asserts  herself 
and  sleep  brings  temporary  relief. 

During  the  progress  of  the  disease,  cutaneous  numbness  or  twitching  of 
some  of  the  muscles,  or  even  paralysis,  gives  the  condition  a  serious  char- 
acter. The  appearance  of  the  patient  is  decidedly  striking,  and  not  to  be 
mistaken.  The  face  is  red,  the  cheeks  puffed  and  swollen,  the  eyes  promi- 
nent, watery,  and  injected,  and  the  conjunctive  quite  red.  He  is  anxious 
and  excited,  or,  on  the  other  hand,  stupid.  The  sleepy  expression  is  one 
of  the  most  valuable  objective  symptoms.  Occasionally,  in  the  course  of 
the  disease,  there  is  bleeding  from  the  nose,  which  may  temporarily  re- 
lieve the  patient.  The  hands  and  feet  are  usually  blue  and  cold,  and  so 
remain.  After  a  variable  period,  during  which  the  patient  has  presented 
a  number  of  these  symptoms,  he  may  suddenly,  after  a  hearty  meal,  or 
violent  exertion  or  some  other  exciting  cause,  suffer  an  incomplete  loss  ot 
consciousness,1  which  is  generally  of  short  duration,  and  from  which  he 
can  be  aroused  in  a  few  minutes.  When  spoken  to  he  seems  bewildered 
and  confused,  and  takes  but  little  notice  of  what  is  going  on  about  him. 
There  seems  to  be  incomplete  loss  of  muscular  power,  more  confined  to 
one  side  than  to  the  other,  and  he  is  able  when  less  dazed  to  make  simple 
voluntary  movements.  He  seems  to  be  annoyed  by  any  bright  light  that 
may  be  let  into  the  room.  His  pupils  are  contracted  usually,  and  respira- 
tion is  labored,  while  circulation  is  uneven,  there  being  an  irregular  pulse. 
At  first  the  heart's  action  seems  to  stop  altogether,  but  subsequently  it  be- 
comes quite  energetic,  and  the  pulse  is  bounding  and  full.  If  the  attack 
be  due  to  passive  congestion,  there  may  be  a  dilatation  of  the  pupils,  and 
the  bloating  and  puffing  of  the  face  and  fulness  of  the  lips  will  be  much 
more  noticeable  than  when  it  is  the  result  of  the  sthenic  variety.  During 
its  continuance  there  is  neither  rigidity  of  the  muscles  nor  stertorous 
breathing.  The  recovery  is  generally  rapid,  and  after  the  apoplectic  form 
of  attack  there  may  be  some  epistaxis  and  slight  mental  excitement.  Oc- 
casionally convulsions  occur  as  an  evidence  of  cerebral  hypertemia,  and 
they  are  generally  of  an  interesting  nature,  from  the  fact  that  they  may 
closely  simulate  epilepsy,  and  have  been  confounded  with  that  disease  by 
certain  writers,  among  them  Trousseau.  These  attacks  are  preceded,  in 
most  cases,  by  prodromata  highly  suggestive  of  cerebral  congestion,  and 
they  usually  need  some  exciting  cause  for  their  production,  when  the 
patient,  after  becoming  dusky,  lapses  into  an  unconscious  condition,  and 
after  ineffectual  attempts  at  self-control  falls  to  the  ground  and  is  agitated 
by  an  epileptiform  convulsion.  Instead,  however,  of  sinking  into  a  deep 
sleep  almost  immediately  afterward,  as  is  the  case  in  true  epilepsy,  he  is 
wild  and  excited,  sometimes  maniacal,  and  finally  sleeps  from  sheer  ex- 
haustion. 

Trousseau  has  stated  that  these  attacks  are  connected  with  tongue-biting, 
but  this  seems  improbable,  and  he  evidently  confuses  this  condition  with 
veritable  epilepsy. 

1  These  symptoms  are,  without  doubt,  due  to  small  hemorrhages. 


72  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

A  form,  which  certain  writers  have  called  maniacal,  may  and  does 
often  occur  without  any  of  the  characteristic  symptoms  of  increased  cere- 
bral blood  pressure  that  I  have  described.  It  is  the  form  Milner  Fother- 
gill  has  so  admirably  described,1  and  characterizes  usually  the  pathological 
condition,  in  which  the  nervous  tissues  attract  an  abnormal  amount  of 
blood  to  themselves.  This  variety  is  not  necessarily  connected  with  vas- 
cular excitement,  suffusion  of  the  face,  etc.  It  results  commonly  from 
protracted  intellectual  labor  and  direct  excitement,  and  the  patients  may 
be  pale  and  bright-eyed,  and  active  in  all  their  movements.  They  are 
"  high-strung,"  restless,  and  remarkably  irritable,  and  at  the  same  time 
are  loquacious  and  voluble.  Their  thoughts  and  fancies  seem  crowded 
together,  and  are  evidently  originated  much  more  rapidly  than  they  can 
be  expressed.  "  Sometimes  their  ideas  seem  to  settle  themselves  around 
gome  prominent  leading  thought,  the  centre-piece  of  the  rotatory  chaos, 
while  at  other  times  there  is  mental  excitement,  with  great  volubility,  on 
no  subject  in  particular."  The  condition  is  one  of  exaltation,  and  there  is 
a  restlessness  which  is  characteristic. 

There  is  rarely  any  forcible  heart  action,  the  pulse  being  normal,  or,  if 
changed  at  all,  is  simply  small  and  irritable.  This  condition  does  not 
seem  to  be  confined  to  any  particular  age,  though  in  old  people  cerebral 
congestion  is  disposed  to  take  this  character.  The  mental  features  may 
be  those  of  ordinary  acute  mania,  and  all  the  phases  of  psychical  disturb- 
ance may  be  expressed  at  some  time  or  other.  Suicidal  tendencies  are 
sometimes  present.  A  case  of  this  kind  is  reported,  where  the  indi- 
vidual, during  an  attack  of  congestive  mania,  cut  his  throat.  The  loss  of 
blood  relieved  the  cerebral  fulness,  and  his  reason  returned,  but  too  late 
to  avert  the  consequences  of  the  act.  This  condition  is  one  of  rapid  pro- 
duction, and  under  prompt  treatment  may  disappear.  Embarrassment  of 
speech  may  vary  from  simple  awkwardness  of  articulation  to  decided 
aphasia.'  The  difficulty  is  rarely  a  serious  or  lasting  one,  and  is  relieved 
by  appropriate  treatment. 

Hammond3  calls  attention  to  a  form  of  aphasia  which  attends  passive 
cerebral  hypercemia,  but  I  consider  this  an  unnecessary  refinement  of 
division. 

As  I  have  before  remarked,  the  second  variety  is  more  apt  to  be  asso- 
ciated with  deep  stupor,  and  recovery  is  less  certain  and  rapid. 

There  may,  indeed,  be  a  form  in  which  profound  stupor,  stertor,  and 
full  hard  pulse  are  present,  and  which  is  almost  always  fatal.  This  follows 
profound  narcosis  by  alcohol  or  opium,  and  the  death  of  the  individual  is 
preceded  by  involuntary  discharge  of  feces  and  urine,  and  there  is  complete 
loss  of  voluntary  muscular  power. 

Before  concluding  the  description  of  the  condition,  it  may  be  well  to  call 
attention  to  a  form  which  is  chiefly  confined  to  early  life,  and  occurs  in 

1  West  Riding  Reports,  art.  Cerebral  Hyperaemia,  vol.  v.  p.  171. 
8  This  grave  form  is  probably  due  to  some  lesion. 
3  Diseases  of  Nervous  System,  N.  Y.  1877,  p.  42. 


CEREBRAL    HYPER^MIA.  73 

the  course  of  other  diseases,  or  it  may  exist  uncomplicated.  In  many  re- 
spects it  resembles  meningitis.  It  is  characterized  by  elevation  of  tempe- 
rature and  other  febrile  symptoms,  among  them  vomiting,  flushed  face, 
headache,  broken  sleep,  twitching  of  the  limbs,  constipation,  and  wandering 
delirium.  Convulsions  occasionally  occur,  and  the  attack  ends  in  deep  sleep. 
Recovery  is  the  rule,  although  the  young  brain  is  so  delicate  and  the  vio- 
lence of  congestive  diseases  so  excessive,  that  a  passive  condition  may  take 
the  place  of,  and  remain  after  the  acute  condition,  and  death  may  ulti- 
mately follow.  Epilepsy  not  rarely  originates  in  this  way. 

Causes. — Calmeil1  and  others  consider  that  men  are  far  more  subject 
to  cerebral  hyperaemia  than  women,  and  I  think  clinical  experience  fully 
supports  their  views.  Some  occupations  and  vices  of  men  are  peculiarly 
apt  to  lead  to  disordered  states  of  the  circulation,  while  women,  as  it  will 
be  seen,  are  not  affected  nearly  so  often  as  the  other  sex,  and  generally 
suffer  only  at  the  menstrual  periods  or  when  there  is  a  retarded  flux.  It 
is  not  confined  to  any  age,  but  is  commonly  a  condition  of  middle  life, 
though  special  causes  may  influence  its  origin  at  other  periods. 

As  to  the  etiological  bearing  of  climate  and  temperature,  there  has  been 
much  discussion.  As  far  back  as  the  time  of  Hippocrates2  we  have  been 
told  that  it  is  a  condition  produced  or  aggravated  by  low  temperature,  in 
which  opinion  he  is  sustained  by  Aretseus.3  Cheyne  and  others  consider 
that  extreme  heat  favors  this  morbid  state,  and  Hammond,  Andral,  and 
others  contend  that  the  greater  number  of  cases  occur  in  cold  weather. 

As  far  as  my  own  experience  is  concerned,  I  have  found,  that  either 
extreme,  heat  or  cold,  may  develop  the  disease,  but  the  greatest  number  of 
my  cases  have  arisen  from  exposure  to  the  direct  rays  of  the  sun,  or  have 
been  among  men  whose  avocation  led  them  to  pass  their  time  in  hot  places. 
Bakers,  sugar-refiners,  furnace-men,  glass-blowers,  etc.  etc.  are  often 
affected,  and  it  is  hard  to  say  whether  these  people,  or  those  who  overuse 
their  brains,  form  the  largest  number.  I  give  below  a  table  which  details 
the  occupation  of  160  of  these  patients. 

One  Hundred  and  Sixty  Cases  of  Cerebral  Hypercemia — Occupation. 


Bartenders 

.     18 

Lawyers 

.     16 

Bakers 

.         .     15 

Musicians 

2 

Blacksmiths 

.     19 

Merchants         . 

.     15 

Carpenters 
Carpet-cleaners 
Foundrymen     . 

.       3 
1 
.       6 

Painters 
Physicians 
Printers 

.       2 

.       6 
2 

Harness-makers 
Jewellers 

2 
2 

Reporters 
Tailors 

4 
1 

Seamstresses 

5 

Teachers           . 

.     13 

Laundresses 

3 

Miscellaneous  . 

.      17 

Laborers 

.       8 

160 

1  Maladies  inflammatoire  du  Cerveau. 

2  Aphor.,  Lect.  iii.  16,  23. 

3  Aretajus  de  Sumi  et  Caus.  rnorbd.  d.  lib.  1,  c.  7. 


74  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

By  this  table  it  will  be  seen  that  64  were  individuals  whose  pursuits 
subjected  them  to  exposure  to  heat,  and  54  were  among  persons  who  were 
hard  students,  worried  business  men,  and  the  like. 

Immediately  after  the  heated  term  of  1872  I  saw  many  patients  whose 
cerebral  condition  was  produced  by  the  great  heat;  but  the  disease 
may  be  due  in  many  instances  to  exposure  and  cold,  or  is  at  least  greatly 
aggravated  by  low  temperature.  Perhaps  a  reason  for  this  may  be  that 
in  cold  weather  the  cutaneous  circulation  is  not  so  active  as  during  the 
warmer  season,  when  the  sudorific  apparatus  requires  a  free  capillary 
circulation,  and  for  this  reason  there  is  a  determination  of  blood  to  the 
surface.  In  cases  of  sunstroke,  as  we  know,  the  skin  is  generally  parched 
and  dry. 

As  to  predisposing  causes  we  may  enumerate  them  as  follows:  The 
organization  of  the  individual,  the  existence  of  other  disease,  his  habits, 
etc.  Two  classes  of  individuals  may  be  the  subjects  of  cerebral  hyperaemia 
— those  of  the  thick -set  plethoric  habit,  which  Reynolds  calls  the  "lax- 
fibred  constitution,"  and  those  who  are  spare,  well  knit,  and  of  nervous 
temperament.  These  latter  individuals  have  generally  hard,  rigid  arteries, 
are  past  middle  age,  and  are  usually  brain-workers. 

In  those  individuals  who  possess  a  well-developed  arterial  system,  but 
such  configuration  of  the  neck  and  head  as  to  prevent  venous  return,  there 
is  a  tendency  to  cerebral  fulness.  There  are  several  morbid  conditions 
which  markedly  influence  the  development  of  this  state — malaria,  renal 
and  cardiac  diseases,  and  syphilis  being  among  the  number.  In  patients 
with  enlarged  and  diseased  kidneys  which  are  unable  to  excrete  the  effete 
nitrogenous  waste  from  the  blood,  it  remains  in  the  circulation,  increasing 
blood  pressure,  and  necessitating  excessive  activity  and  rapidity  of  heart 
action.  Hypertrophy  of  that  organ  is  a  result,  and  the  walls  of  the  right 
ventricle  become  greatly  enlarged  ;  and  having  much  greater  force  than  it 
possesses  in  its  normal  condition,  it  forces  the  blood  with  great  energy  into 
the  cerebral  vessels,  and  as  a  result  there  is  produced  the  morbid  condition 
of  which  we  have  spoken.  Pulmonary  disease,  attended  by  diminished 
aerating  space,  sometimes  has  the  same  influence.  Gout  may  be  at  the 
origin  of  cerebral  hyperaemia ;  and,  as  I  have  said,  malaria  very  often  plays 
a  very  important  part  in  the  etiology. 

Syphilis  I  have  found  to  have  much  to  do  with  cerebral  hyperaemia.  In 
this  disease  this  condition  of  the  cerebral  vessels  is  not  uncommon  during 
the  secondary  and  tertiary  stages,  but  more  often  during  the  latter.  Men- 
tal perturbation  and  hysteria  seem  to  be  connected  with  these  forms. 

An  excessive  indulgence  in  alcohol,  immoderate  eating  and  drinking, 
or  the  abuse  of  tobacco;  continued  venery,  and  disregard  of  the  ordinary 
calls  of  nature,  are  all  predisposing,  and  some  of  them  exciting,  causes. 
Protracted  or  unnatural  intellectual  labor,  emotional  disturbance,  mental 
strain,  and  intense  excitement  of  various  kinds,  are  additional  causes  of 
great  importance. 

Intellectual  labor  at  night,  particularly  when  there  is  a  gas-light  above 
the  head  of  the  patient,  or  prolonged  business  worry,  not  rarely  favors 


CEREBRAL    HYPER^MIA.  75 

the  determination  of  blood  to  the  brain.  Night  editors,  students,  and 
workers  by  artificial  light  are  subject  to  this  condition,  and  eye-strain 
from  these  occupations  is  a  powerful  factor  in  the  causation. 

Myopia  and  various  errors  of  refraction  and  accommodation  are  some- 
times at  the  origin  of  severe  headaches  of  the  congestive  variety.  Pro- 
longed grief,  especially  when  the  patient  neglects  his  bodily  comfort, 
and  passes  long  days  in  mourning,  eating  little,  and  gaining  no  sleep,  is 
also  a  cause.  The  acute  condition  is  not  rare  among  nurses  who  have  sat 
up  at  night ;  and  they,  as  well  as  other  night-workers,  are  very  apt  to 
combat  the  disposition  to  sleep  which  is  healthy,  by  stimulants,  coffee,  or 
other  agents,  and  after  a  short  period  a  disagreeable  state  of  congestion 
follows. 

As  distinct  exciting  causes  I  may  mention  alcoholic  abuse — pressure 
made  upon  the  veins  of  the  neck  by  tight  collars  or  other  articles  of  dress 
— sudden  exertion  of  any  kind,  such  as  straining  at  stool,  or  during  child- 
birth, and  lifting  heavy  weights.  In  one  of  my  patients,  the  simple  act 
of  bending  over  to  button  his  shoe  was  sufficient  to  produce  an  alarming 
condition  of  the  cerebral  circulation.  In  some  persons  the  condition  is 
aggravated,  or  attacks  of  the  severer  kind  are  precipitated  by  a  visit  to  the 
theatre  or  some  crowded  place  of  amusement,  where  ventilation  is  bad  and 
the  room  heated  to  a  high  temperature. 

Pathology.1 — Almost  enough  has  been  said  to  explain  the  changes 
which  occur  during  the  development  of  a  morbid  state  of  intra-cranial 
circulation.  Fothergill  intelligently  divides  the  processes  which  may  induce 
this  condition  as  the  following:  1.  It  may  occur  as  a  vascular  form,  with 

1  By  far  the  most  important  and  interesting  part  of  the  study  of  brain  histology 
is  the  intricate  and  beautiful  arrangement  of  the  perivascular  space  discovered 
by  Robin*  and  His,f  and  described  by  them  as  well  as  by  Bastian,J  Fothergill, 
and  others.  His  demonstrates  the  existence  of  these  small  spaces  which 
surrounded  the  vessels,  than  which  they  were  several  times  larger.  He  found 
them  in  greater  numbers  in  the  gray  substance,  and  thought  he  discovered  a 
communication  between  the  spaces  in  the  brain  and  cord  and  certain  lymph-ducts 
in  the  pia  mater. 

The  office  of  these  canals  which  loosely  contain  the  vessels,  with  which  they 
have  no  attachment,  is  a  most  important  one;  for,  notwithstanding  the  fact  that 
the  force  of  blood  (particularly  that  which  goes  to  the  cerebrum)  is  moderated  by 
the  tortuous  course  of  the  arteries  after  they  enter  the  cranium,  and  their  com- 
plete subdivision  when  they  are  distributed  over  the  pia  mater,  the  nervous  sub- 
stance would  be  little  prepared  without  such  an  arrangement  for  sudden  and 
violent  accession  of  blood. 

This  space  or  cavity  about  all  of  the  vessels  enables  them  to  expand  to  a  great 
extent  without  any  actual  pressure  being  made  upon  the  adjacent  delicate  tissues. 
When  such  a  determination  of  blood  occurs,  the  perivascular  fluid  is  driven  out  ot 
the  nervous  substance  proper,  and  after  the  hyperajmia  subsides,  returns  to  the 
spaces  about  the  vessels. 

*  Compte  Rendu  de  la  Soc.  Biol.,  Paris,  1855. 

f  Zeitschrift  fur  Wiss.  Zoologie,  Band  15.' 

J  Notes  to  translation  of  His's  paper,  Journal  of  Anatomy,  vol.  1. 


16  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

increased  blood  pressure,  and  be  dependent  upon  extra-cranial  agencies. 
2.  It  may  result  from  tissue  alterations,  in  which  the  blood  is  attracted  to 
the  brain,  or  it  may  result  from  toxic  agents,  when  the  two  former  modes 
are  combined. 

Through  the  cerebral  ventricular  connection  and  the  spaces  in  the 
arachnoid  we  have  reservoirs  for  accumulation  of  this  fluid,  when  the  blood 
pressure  is  diminished,  and  a  loose  and  capacious  receptacle  in  th<  spinal 
arachnoid  sacs  for  containing  this  fluid  when  the  blood  pressure  is  above  the 
average,  so  that  the  balance  is  generally  preserved.  When  the  harmony 
of  this  arrangement  is  disturbed,  we  may  expect  to  find  evidences  of  such 
inequality. 

Now  the  question  of  the  extent  to  which  the  brain  may  be  compressed 
without  injury,  is  one  which  I  think  will  bear  more  discussion  than  it  has 
hitherto  received.  Not  only  are  the  present  means  for  experimentation 
inadequate,  but  there  are  certain  puzzling  questions  that  come  up  in  the 
most  unexpected  manner.  The  experiment  of  suspending  the  subject, 
constricting  the  vessels,  and  measuring  the  blood  pressure  by  instruments 
devised  for  the  purpose,  have  been  tried.  Dr.  Loring1  has  related  an  in- 
stance where  the  first  experiment  was  made,  and  I  shall  use  his  own 
words :  "  I  would  mention  that  a  patient  of  mine,  the  acrobat  known  as 
the  '  Champion  Fly  Walker,'  informed  me  that  in  walking  across  the  ceil- 
ing of  a  theatre,  head  downwards,  he  never  felt  the  slightest  disturbance 
in  his  vision,  though  the  feat  occupied  fifteen  or  twenty  minutes.  This 
would  go  to  show,  also,  that  position  did  not  have  so  marked  an  influence 
on  the  quantity  of  either  blood  or  serum  in  the  interior  of  the  head  as  is 
now  believed  to  be  the  case.  For  it  hardly  seems  possible  that  the  quan- 
tity of  blood  could  be  either  increased  or  diminished  to  any  considerable 
degree,  even  at  the  expense  of  the  other  fluids,  and  yet  allow  one  to  main  • 
tain  for  so  long  a  time  such  a  complete  control  over  the  faculties,  espe- 
cially that  of  coordination,  as  to  perform  so  dangerous  a  feat,  and  one 
which  demanded  so  nice  an  application  of  the  senses.  Be  this  as  it  may, 
I  must  say  I  have  never  been  able  to  see  the  great  weight  of  Kellie's  and 
Burrows'  experiments  with  animals  which  were  killed  and  then  suspended 
by  the  head  or  heels,  as  the  case  might  be." 

When  an  individual  is  thus  suspended,  we  are  furnished  with  all  the 
external  indications  of  cerebral  hyperfemia — the  flushed  face,  prominent 
eyes,  etc. — but  consciousness  is  unimpaired,  and  is  not  lost  until  some 
time  has  elapsed.  This  question  is  of  interest,  for  it  suggests  the  idea  that 
perhaps  after  all  many  of  the  changes  in  cerebral  function  are  due  to  the 
shock  sustained  by  nerve-cells  by  the  sudden  accession  of  blood,  and  not 
so  much  to  the  mechanical  pressure  exerted. 

As  to  the  value  of  other  methods  for  studying  the  state  of  the  cerebral 
circulation  by  gauges,  watch-glasses  luted  into  the  skull,  etc.,  I  am  rather 
sceptical.  The  cranial  cavity  is,  of  course,  a  closed  cavity,  and  the 

1  Am.  Psyeholog.  Journ.,  Nov.  1875. 


CEREBRAL    HYPER^EMIA.  77 

blood  supply  of  its  contents  is  modified  by  the  pressure  of  the  bony  wall. 
Any  perforation  must  admit  the  external  air,  and  the  intra-cranial  blood 
is  then  circulating  under  an  atmospheric  pressure,  and  I  am  strongly 
convinced  such  variations  as  have  been  described  are  not  those  that  take 
place  in  the  normal  state. 

I  have  said  sufficient  in  detailing  the  causes  of  cerebral  hyperamia  to 
explain  any  pathological  processes,  the  description  of  which  I  may  now 
pass  over. 

Morbid  Anatomy — Upon  removing  the  calvarium  the  observer 
will  probably  meet  with  some  if  not  all  of  the  following  appearances. 
Dura  mater  and  underlying  membranes  injected  and  pink,  or  opal- 
escent, and  sometimes  quite  free  from  moisture,  resembling  in  this  re- 
spect a  piece  of  damp  sheepskin.  The  sinuses  may  be  filled  with  dark 
blood,  and  the  surface  of  the  brain  flattened  and  of  a  deeper  color  than 
normal.  The  convolutions  may  be  flattened  and  pressed  down  so  that 
the  sulci  are  defined  in  sharp  lines,  the  inner  surface  of  the  convolutions 
being  pressed  together.  The  surface  of  the  brain,  as  I  have  said,  is  dark, 
and  if  the  pia  mater  is  torn  off  fluid  blood  may  escape  from  the  separated 
vessels.  Upon  making  sections  in  a  transverse  plane  the  observer  will  be 
sometimes  struck  by  the  appearance  of  a  pinkish  blush,  visible  in  spots, 
which  is  due  to  staining  by  haematoidin.  This  appearance,  alluded  to 
by  Fox,1  has  been  compared  tosspots  of  red  sand  dusted  on  the  surface. 
The  corpora  striata  are  of  a  very  deep  red  or  even  violet  color,  and  the 
white  matter  contains  small  puncta  which  are  red  or  dark  purple.  The 
vessels  are  generally  enlarged,  tortuous,  and  filled  with  quite  dark  blood. 
Calmeil3  has  presented  the  records  of  autopsies  in  a  number  of  cases  of 
temporary  duration.  He  found  "  in  three  cases  that  the  cranial  bones 
were  notably  injected ;  in  three  the  vessels  of  the  dura  mater  were  con- 
gested ;  in  one  case  there  was  fibrinous  coagulation  in  the  longitudinal 
sinus ;  in  one  the  internal  surface  of  the  dura  mater  was  furrowed  by 
capillary  arborizations  ;  in  two  the  cavity  of  the  arachnoid  contained  liquid 
blood  and  bloody  humidity  ;  in  four  the  cerebral  pia  mater  was  generally 
congested ;  in  three  cases  it  was  reddened  by  extravasated  blood  ;  in  one 
the  pia  mater  adhered  in  spots  to  the  subjacent  convolutions ;  in  one  these 
convolutions  on  the  right  side  were  swollen  ;  in  four  the  cortical  substance 
of  the  brain  was  generally  injected  and  more  or  less  colored  by  haematosin," 
etc.  etc.  We  therefore  must  arrive  at  the  conclusion  that  there  is  nothing 
remarkably  significant  in  regard  to  the  seat  of  the  congestion  or  its  form. 
The  violence  of  the  symptoms  will,  of  course,  be  proportionate  to  the  extent 
of  hyperiemia,  though  this  is  not  always  the  rule ;  and  I  have  seen  cases,  and 
I  think  others  also  have,  in  which  profound  coma  and  speedy  death  were 
preceded  by  unmistakable  symptoms  of  hyperaemia,  such  as  contraction  of 
the  pupils,  etc.,  and  after  death  very  slight  evidences  of  congestion  were 
perceptible.  Microscopical  examination  reveals  in  old  cases  a  condition 

1  Pathological  Anatomy  of  Nervous  Centres,  p.  55. 

2  Quoted  by  Fox,  p.  56. 


78 


DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 


which  has  been  called  by  various  writers  "  1'Etat  crible."  This  consists 
of  a  peculiar  spongy  worm-eaten  appearance.  Arndt  says  that  when  tin'-.- 
lymph-spaces  are  dilated  they  are  filled  with  effete  material  from  the 
brain  resembling  amyloid  substance  or  leucin,  called  by  him  hyaline.  Tin- 
peri  vascular  spaces  are  very  large,  and  openings  of  some  size  are  found  at 
points  where  vessels  have  been  cut  across.  These  are  due  to  the  abnormal 

Fiir.  11. 


Distended  Porivascnlar  Spaces,  with  Atrophy.     (Fothergill.) 

pressure  made  by  the  distended  vessel  and  the  destruction  of  adjan-nt 
nervous  tissue.  Calmeil,  Van  der  Kolk,  Durand-Fardel,  and  lately  Arndt.1 
have  accounted  for  them  as  the  result  of  oedema  of  the  perivascular  space. 
This  appearance  is  a  constant  one  in  all  brains  where  there  has  been 
continued  hyperaemia,  and  especially  in  the  brains  of  drunkards.  The 
bloodvessels,  when  not  destroyed,  will  be  found  to  be  tortuous  and  varicose, 
and  coated  oftentimes  by  a  granular  shining  deposit.  The  pia  mater  is 
thickened,  and  its  vessels  present  the  appearance  just  described  perhaps 
better  than  any  other  tissue. 

Diagnosis — The  condition  in  its  early  stages  may  be  mistaken  for 
the  opposite  state,  cerebral  anaemia  ;  in  fact,  the  diagnosis  is  always  full 
of  difficulties. 

An  inspection  of  the  following  table  may,  however,  furnish  us  with 
hints  so  that  we  may  be  enabled  to  separate  cerebral  congestion  from 
cerebral  ana-mia.  It  will  be  observed  that  some  of  the  symptoms  are 
closely  allied. 

1  Virchow's  Archiv,  Ixiii.  p.  24. 
I 


CEREBRAL    HTPER^EMIA.  79 

CEREBRAL  CONGESTION.  CEREBRAL  ANEMIA. 

Headache  (generally  diffused).  Headache  (chiefly  vertical.) 

Noises  in  the  ears,  generally  "rum-  Noises  in  the  ears  (generally  sharp  or 

bling,"  or  singing.  short). 

Mental  disturbance — loss  of  memory,  Mental  disturbance — incapacity  for 

hallucination.  mental  work. 

Pupils  contracted.  Pupils  dilated. 

No  heart  sounds,  except  perhaps  those  Pulse  irritable,  aortic  murmurs,  sphyw- 

of  insufficiency.  Pulse  full.  mographic  tracing  almost  straight. 

Urine  not  increased,  generally  con-  Urine  passed  in  large  quantities,  is 

tains  urates  and  phosphates.  clear  and  limpid. 

In  the  apoplectic,  convulsive,  and  paralytic  forms  there  is  little  danger 
of  making  a  mistake. 

These  phenomena  are  sometimes  liable  to  be  mistaken  for  meningeal  or 
cerebral  hemorrhages,  cerebral  embolism  or  thrombosis,  epilepsy,  ursemic 
coma,  etc. 

The  apoplectic  variety  may  be  confused  with  cerebral  or  meningeal 
hemorrhage.  When  we  bear  in  mind  that  in  the  former  there  is  generally 
almost  transitory  loss  of  consciousness  and  motor  power,  that  hemiplegia 
is  not  always  present,  and  that  marked  stertor  is  rarely  found,  there  is  no 
room  for  a  mistake  in  diagnosis. 

The  other  varieties  of  cerebral  trouble,  namely,  embolism  and  throm- 
bosis, may  be  disposed  of  by  calling  to  mind  the  sudden  appearance  of 
symptoms  in  the  former ;  its  association  with  cardiac  vegetations,  and  its 
permanent  after-effects. 

A  case  of  this  kind  presents  itself  to  my  mind.  A  gentleman,  brought 
to  me  by  Dr.  Asch,  of  New  York,  had  been  told  by  some  friend  that  his 
nervous  symptoms  were  doe  to  embolism.  They  were  these  :  Three 
months  before,  while  sitting  in  his  studio,  he  lost  consciousness,  and  fell 
over  upon  an  unfinished  picture.  He  was  conscious  of  his  condition,  but 
could  not  help  himself.  The  room  became  dark,  and  he  "  saw  spots  before 
his  eyes."  He  recovered  himself  in  a  few  minutes,  and  resumed  his 
work.  A  week  ago  a  similar  attack  occurred  as  he  was  crossing  the  street, 
but  he  was  unable  to  rise  from  the  mud  before  assistance  came.  He  had 
been  worried  by  his  business,  had  worked  very  hard,  and  had  kept  irregu- 
lar hours.  There  was  no  aural  disease.  On  neither  occasion  did  the 
attack  occur  after  a  hearty  meal.  He  had  no  heart  symptoms  at  all. 
After  each  attack  he  recovered  when  he  took  the  needed  rest,  and  then 
saw  no  evidence  of  permanent  trouble.  The  suddenness  of  his  attack 
suggested  embolism,  but  as  no  paralysis  nor  aphasia  followed,  and  no 
after-symptoms  remained,  it  seemed  out  of  the  question  to  consider  this 
his  disease.  I  made  the  diagnosis  of  local  cerebral  hypenemia. 

"With  embolism  there  is  also  generally  pallor  of  the  face,  and  absence  of 
vascular  excitement. 

Thrombosis  is  a  disease  of  slow  and  steady  progress,  with  well-marked 


80  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

symptoms,  and  finally  decided  hemiplegia.  Aphasia  is  also  a  character- 
istic accompaniment  of  thrombosis  as  well  as  embolism. 

Cerebral  softening  can  hardly  be  mistaken  for  the  disease  under  con- 
sideration, because  the  former  is  nearly  always  preceded  by  partial  cerebral 
an;i'in  ia,  or  else  some  distinctly  inflammatory  trouble.  In  cerebral  softening 
there  is  decided  local  pain,  very  intense,  and  never  absent.  Convulsive 
movements,  paralysis,  and  other  decided  indications  mark  the  course  of 
the  softening. 

Unemic  coma  may  be  distinguished  by  its  deep  character,  and  usually 
by  an  examination  of  the  patient's  urine. 

The  epileptic  attacks  of  cerebral  congestion  resemble  those  of  true  epi- 
lepsy very  closely,  and  in  many  cases  we  must  not  be  too  positive.  There 
is,  however,  rarely  any  disposition  to  sleep,  and  the  attacks  are  generally 
preceded  by  some  excitement,  and  are  not  ushered  in  by  the  cry. 

Prognosis — The  lighter  forms  of  this  morbid  condition  are  usually 
amenable  to  treatment,  at  least  this  has  been  my  own  experience.  Of 
course  we  must  be  governed  by  the  duration  of  the  disease,  the  existence 
of  other  affections  of  an  organic  nature,  and  the  age  of  our  patient.  If 
he  be  over  fifty  his  chances  of  ultimate  recovery  are  bad,  but  if  he  has 
not  passed  middle  life,  and  the  condition  is  directly  dependent  upon  some 
exciting  cause  that  can  be  easily  removed,  we  may  express  ourselves  more 
cheerfully.  The  existence  of  calcareous  vessels  is  not  an  agreeable  cir- 
cumstance, nor  the  fact  that  he  has  had  previous  attacks  of  an  apoplectic 
or  paralytic  nature.  Perhaps  the  most  grave  prognosis  is  attached  to  the 
maniacal  form  in  which  the  delirium  is  not  violent  nor  noisy,  but  incessant 
muttering,  and  in  which  there  is  a  restlessness  and  desire  for  constant 
muscular  exertion.  The  great  danger  seems  to  be  in  the  continuance  of 
the  hypenemic  condition,  and  the  possibility  of  its  termination  in  cerebral 
hemorrhage,  meningitis,  cerebritis,  or  other  organic  affections.  "\Vith  a 
hyportrophied  ventricle  and  renal  disease  the  patient  has  little  to  be  thank- 
ful for,  and  we  must  always  give  such  cases  a  very  guarded  prognosis. 

Treatment. — Of  course  the  first  indication,  after  inquiry  into  the 
patient's  habits  and  mode  of  life,  is  to  discover  and  remove  the  predispos- 
ing and  exciting  causes  if  possible.  The  next  is  to  diminish  blood  pressure, 
and  restore  the  lost  equilibrium  of  the  intracranial  blood  pressure  both  by 
local  and  general  treatment. 

In  the  majority  of  cases,  the  most  simple  treatment,  with  attention  paid 
to  the  patient's  bad  habits,  will  generally  remove  the  condition.  Absti- 
nence from  alcohol  in  some  cases,  attention  to  the  bowels,  and  the  pre- 
caution of  keeping  the  head  cool  and  the  neck  unconfined,  are  the  first 
observances  to  be  followed  by  the  physician  and  patient. 

If  the  condition  be  continued,  or  not  relieved  by  these  means,  we  may 
make  use  of  several  remedies,  among  them  the  bromides  (F.  23,  F.  6), 
ergot  (F.  5),  and  hydrobromic  acid  (F.  15).  The  bromides,  which  were, 
I  believe,  first  used  for  this  purpose  by  Clifford  Albutt,  and  Drummond, 
promptly  effect  a  diminution  in  arterial  tension  and  cerebral  blood  pressure. 
Max  Schuler  is  of  the  opinion  that  they  contract  the  small  vessels,  while 


CEREBRAL    HYPERJ3MIA.  81 

Northnagle  thinks  their  chief  action  is  upon  the  nerve  cells.  The  bromide 
of  sodium  I  consider  the  most  potent  of  these  salts,  and  in  doses  of  twenty 
grains,  three  times  a  day,  we  may  expect  the  best  results.  It  is  well  to  com- 
bine it  with  some  cardiac  sedative  when  there  is  tumultuous  heart  action, 
or  with  some  heart  tonic  when  there  is  a  suspicion  that  the  heart  impulse 
is  not  sufficient  to  properly  drive  the  blood  through  the  brain.  Aconite  in 
one  case,  or  digitalis  in  the  other,  is  a  good  agent,  and  may  be  combined 
with  other  drugs  (FF.  1,  2).  If  there  be  much  excitement,  and  the  mind 
of  the  individual  be  irritable,  chloral  may  be  advantageously  administered 
(FF.  4,  3). 

Ergot  or  its  aqueous  extract  is  sometimes  of  great  benefit  in  these 
cases.  Dr.  Kitchen  has  fully  described  its  virtues,  and  my  own  experi- 
ence is  directly  confirmatory  of  all  that  he  has  said.  In  doses  of  3j  three 
times  a  day,  the  fluid  extract  may  be  safely  administered.  Squibb's  or 
Bonjean's  watery  extract,  in  five-grain  doses,  may  be  given  alone  or  in 
combination  with  the  bromide.  Should  the  patient  be  very  much  debili- 
tated, for  this  condition  is  not  rarely  connected  with  general  debility, 
we  may  give  strychnia,  phosphorus,  iron,  or  quinine  (FF.  8,  9,  10,  11, 
12),  though  extreme  care  should  be  taken  in  deciding  when  they  are  useful 
or  contraindicated. 

If  our  patient  should  not  be  able  to  bear  iron,  we  may  substitute  either 
zinc  or  arsenic  (FF.  13,  14).  In  the  forms  where  this  treatment  is  re- 
quired, viz.,  those  where  there  seems  to  be  a  sluggishness  of  the  circulating 
blood,  it  is  well  to  use  this  treatment  instead  of  the  bromides  or  ergot. 

During  sudden  attacks,  local  blood-letting  is  advisable,  leeches  being 
applied  to  both  ears,  and  cups  over  the  mastoid  processes.  Cold  to  the 
upper  part  of  the  head,  applied  by  means  of  a  bladder  or  ice  bag  filled 
with  cold  water  or  powdered  ice,  are  important  branches  of  treatment. 
I  direct  my  patients  to  apply  cold  to  the  back  of  the  neck  for  fifteen 
minutes,  every  night  and  morning,  and  find  that  it  succeeds  admirably. 

A  drug  spoken  of  before  is  hydrobromic  acid,  which  I  have  found  to  be 
a  valuable  and  powerful  amemiant. 

In  the  Philadelphia  Medical  Times  of  October  28,  187G,  the  reader 
will  find  an  article  in  which  1  first  advocated  the  use  of  a  solution  of  hydro- 
bromic acid  in  cerebral  hyperremia. 

Dr.  Fothergill  in  a  subsequent  article  confirmed  my  views  most  fully, 
and  I  have  since  been  gratified  to  find  how  my  expectations  were  realized 
by  a  more  extended  use  of  the  remedy. 

In  small  doses  it  acts  very  much  as  do  the  bromides,  but  witli  much 
more  intensity.  Half  a  drachm  is  fully  equal  to  one  drachm  of  the  bromide 
of  potassium.  It  differs,  however,  in  the  want  of  permanence  of  its  effects 
the  bases  of  the  bromic  salts  seeming  to  favor  retention. 

My  own  experience  in  its  use  has  been  limited  ;  but  from  the  inspection 
of  the  following  cases,  which  are  briefly  sketched,  its  value  will  be  appre- 
ciated. 

CASE  I Miss  C.,  aged  24,  school-teacher  in  a  large  public  school-room, 

many  hours,  the  air  of  which  is  very  impure,  and  towards  the  end  of  the 
6 


82  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

day  her  headache  begins.  "  Her  head  seems  too  big  for  her  body,"  face 
flushed,  eyes  red,  respiration  troubled.  (This  was  the  condition  before 
the  summer  holidays.)  A  vacation  did  very  little  good.  She  now  com- 
plains of  the  same  symptoms.  Towards  night,  her  temporal  vessels  throb ; 
she  has  "  rushes  of  blood."  There  has  been  some  dysmenorrhoea.  On 
August  28,  she  consulted  me,  when  I  prescribed  hydrobromic  acid  3j>  t.  i. 
d.  Sept.  14,  entirely  relieved.  A  menstrual  period  was  afterwards  passed 
without  pain. 

CASE  II G.  J.,  31,  clerk.  At  his  desk  many  hours  daily.  Complains 

of  confusion  of  ideas,  inability  to  fix  his  mind  upon  his  work,  indisposed 
to  exertion,  smokes  to  excess,  insomnia,  and  incapacity  for  work.  The 
top  of  his  head  is  hot,  and  the  conjunctivas  injected.  HBr.  5j»  t.  i.  d. 
Complete  relief  in  a  week.  This  condition  had  lasted  several  months. 

CASE  III — Mr.  D.,  36,  "  man  about  town."  His  habits  are  bad ; 
drinks  hard,  and  keeps  very  late  hours.  Is  being  treated  for  syphilitic 
trouble.  Has  had  head-fulness,  insomnia,  indisposition  to  take  exercise, 
gradual  loss  of  memory  for  the  past  ten  years.  He  formerly  masturbated. 
Very  hysterical  and  worried  about  himself.  There  are  many  dysaesthesiae, 
but  also  .evidences  of  head-trouble.  The  eyes  are  red,  prominent,  and 
watery,  and  the  temporal  vessels  stand  out  like  cords.  At  night  his  sleep 
is  troubled,  and  it  is  some  time  before  he  can  forget  himself.  His  urine 
contains  phosphatic  deposits.  HBr.  3J?  t.  i.  d.,  before  eating.  Two  months 
after  (Sept.  15),  perfectly  well,  except  syphilis. 

CASE  IV — Miss  M.  E.  R.,  22.  Insomnia  is  the  condition  which  most 
annoys  this  patient,  and  when  in  bed  her  feet  become  cold.  "  It  seems," 
she  said,  "  as  if  all  the  thoughts  I  ever  had  were  crowded  into  the  long 
weary  hours  I  pass  before  sleep  comes."  She  fears  insanity,  and  is  in  a 
pitiable  mental  state.  The  bromides  have  lost  their  effect.  A  drachm 
and  a  half  of  hydrobromic  acid  procured  sleep  the  first  night. 

With  regard  to  diet  and  indulgence  in  alcohol  and  tobacco,  tea  or  coffee, 
it  is  impossible  to  lay  down  any  arbitrary  rules.  I  may  begin,  however, 
by  interdicting  all  the  meats  difficult  of  digestion,  and  recommending  a 
non -nitrogenous  diet.  Veal,  corned-beef,  pork,  and  certain  vegetables, 
such  as  cabbage,  cauliflower;  or  nuts,  spices,  bananas,  and  other  aromatic 
or  fatty  substances,  are  not  to  be  thought  of.  Simplicity  of  diet  is  to  be 
insisted  upon.  Meats  should  be  broiled,  roasted,  or  baked ;  and  vegeta- 
bles Iwiled.  If  the  patient's  comfort  is  dependent  upon  tea  or  coffee,  it 
would  be  well  to  permit  him  to  indulge  in  them  to  a  reasonable  extent.  I 
do  not  consider  tobacco  is  the  dangerous  agent  that  it  is  often  said  to  be. 
If  the  individual  be  a  smoker,  I  think  his  after-dinner  cigar  need  not  be 
cut  off,  and  a  glass  or  two  of  wine  is  not  in  the  least  harmful.  Burgundy, 
Port,  or  other  full-bodied  wines  should  be  given  up  as  a  matter  of  course. 
The  abuse  of  alcohol  and  tobacco  is  to  be  looked  after  and  stopped,  if  we 
have  any  reason  to  think  that  the  patient  has  these  bad  habits.  Open-air 
exercise ;  cold  baths,  with  friction  ;  or  the  Turkish  bath,  and  other  agents 
that  tend  to  improve  the  cutaneous  circulation,  do  a  great  deal  of  good, 
and  are  to  be  indulged  in.  We  must  insist  upon  the  avoidance  of  excite- 
ment, dissipation,  and  late  hours  and  theatre-going;  and  it  may  be  well  to 
lay  before  our  patient  what  may  be  the  result  of  such  imprudence.  Should 
we  be  called  in  to  find  that  the  disease  has  manifested  itself  in  either  of 


CEREBRAL    HEMORRHAGE.  83 

the  forms  I  have  alluded  to  (the  apoplectic,  convulsive,  paralytic,  or 
maniacal),  we  must  order  perfect  quiet,  darken  the  room,  and  use  every 
means  in  our  power  to  reduce  the  cerebral  blood  pressure. 


CEREBRAL  HEMORRHAGE. 

Synonyms — Apoplexy.  Haemorrhagia  cerebria  (Lat.).  Apoplexie 
cerebrale;  hrematcencephalie ;  coup  de  sang;  haemorrhagie  cerebrale  (Fr.). 
Hirnapoplexieen  (Ger.). 

Definition — When  through  disease  of  a  vessel  its  walls  are  unable 
to  withstand  the  pressure  of  contained  blood,  a  hemorrhage  takes  place, 
and  the  nervous  substance  in  the  neighborhood  may  be  subjected  to  pres- 
sure. The  severity  of  the  resulting  symptoms  depends,  of  course,  upon 
the  importance  of  the  parts  which  may  be  the  seat  of  the  accident,  and 
upon  the  extent  of  the  hemorrhage. 

Symptoms — I  have  already  alluded,  when  speaking  of  cerebral  con- 
gestion, to  light  forms  of  hemiplegia  of  temporary  duration,  which  were 
dependent  upon  slight  hemorrhages  resulting  from  cerebral  congestion. 
We  will  now  deal  with  a  form  of  cerebral  hemorrhage  of  a  more  serious 
character,  and  it  may  be  stated  that  the  brain  is  probably  more  liable  to 
hemorrhage  than  any  other  organ,  with  the  exception,  perhaps,  of  the 
spleen.1 

Bastian  has  made  the  classification  which  I  think  it  well  to  follow.  He 
divides  cerebral  hemorrhage  into  three  forms,  in  regard  to  the  onset  of 
symptoms  :  (1)  The  apoplectiform  ;  (2)  the  epileptiform  ;  (3)  the  simple, 
in  which  there  is  neither  loss  of  consciousness,  nor  convulsions.  The 
first  may  be  considered  as  a  sudden  and  profound  loss  of  consciousness, 
which  may  or  may  not  disappear  ;  but,  if  it  does,  a  certain  amount  of  hemi- 
plegia will  remain.  The  epileptiform  resembles  the  first,  but,  in  addition 
to  the  coma,  there  are  convulsions.  As  I  have  said,  the  simple  variety 
may  not  be  connected  with  any  loss  of  consciousness,  the  patient,  perhaps, 
awaking  in  the  morning  and  finding  himself  deprived  of  power,  or  noticing 
such  a  loss  when  some  movement  is  attempted. 

Prodromata Cerebral  hemorrhage  occurs  generally  in  individuals  in 

whom  some  well-developed  chronic  trouble  has  paved  the  way.  This  is 
the  rule,  although  in  many  cases  it  may  be  the  result  of  some  recent  dis- 
ease. When  we  come  to  speak  of  pathology  and  morbid  anatomy,  these 
general  diseases,  and  their  influence  in  the  production  of  degeneration  of 
the  cerebral  arteries,  will  be  discussed  ;  it  is  only  necessary  now  to  describe 
the  forms  of  expression  of  the  preparatory  stages.  It  is  not  always  neces- 
sary to  look  for  indications  spoken  of  by  Hughlings  Jackson.*  "  The 
careful  clinical  observer  considers  minor  degenerative  changes,  baldness, 
grayness  of  hair,  the  state  of  skin,  and  worn  teeth.  He  inquires  for  the 
history  of  gout  and  intemperance." 

1  Paralysis  from  Brain  Disease,  p.  14. 

*  Cerebral  Hemorrhage,  "Reynolds'  System  of  Medicine." 


84  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

The  appearance  of  these  individuals  in  whom  an  apoplectic  effusion 
may  be  looked  for,  may  be  of  two  kinds.  1.  The  thick-necked,  red-fac-< •<!. 
and  full-blooded.  2.  The  fair,  long-necked,  or  aged  persons,  in  whom  tin- 
radial  arteries  are  hard,  and  feel  very  much  like  strings  of  beads  or  pipe- 
stems  beneath  the  skin.  The  existence  of  renal  trouble  also  contributes  to 
the  development  of  an  arterial  state  which  favors  rupture,  and  we  should 
look  for  other  indications  of  this  trouble.  Many  of  the  symptoms  of  cere- 
bral hypenemia  may  be  precursors  of  those  that  follow  cerebral  hemor- 
rhage. For  several  days  the  patient  may  have  headache,  formication  at  the 
extremities  as  if  pins  and  needles  were  being  thrust  into  the  skin,  perhaps 
a  slight  anesthesia  of  the  arm  or  leg  of  one  side  ;  his  speech  may  be  thick 
and  clumsy,  or  he  may  drop  a  word  here  and  there,  and  his  eyes  may  be 
red  and  full  of  tears ;  dizziness,  muscze  volitantes  dependent  upon  retinal 

extravasation,  and  nose-bleed  may  all   be  indications  of  increased  bl 1 

pressure.     These  last  two  forerunners  of  cerebral  hemorrhage  may  recur 
at  intervals  for  some  time  before  the  actual  rupture  of  the  vessel.     The 
retinal  trouble  may  be  of  long  duration,  and  is  of  decided  importance  as 
an  evidence  of  the  degenerate  condition  of  the  cerebral  vessel,  and  should 
invariably  be  regarded  with  suspicion.     An  atrophy  of  the  optic  papillae 
with  spots  of  blanching  at  the  fundus,  such  as  we  find  to  be  the  result  of 
Bright's  disease,  is  also  suggestive  at  times  of  a  tendency  to  cerebral  hem- 
orrhage.    To  this  list  of  prodromata  may  be  added  vomiting  and  stupor ; 
but  these  are  connected  with  so  many  varieties  of  brain  disease  that  they 
may  only  be  considered  as  important  when  occurring  in  conjunction  with 
the  trouble  to  which  I  have  just  alluded.     A  very  serious  premonitory 
symptom  is  paralysis  of  one  limb  or  certain  isolated  muscles,  which  indi- 
cates organic  disease.     After  a  variable  time,  during  which  some  or  all  of 
these  antecedent  symptoms  may  be  observed,  the  vascular  accident  may 
occur.     Its  onset  may  take  place  in  two  ways :  (a)  In  connection  with 
profound  loss  of  consciousness  and  suddenly,     (b)  Gradually,  without  loss 
of  consciousness.     We    may  call  the  first    the    apoplectic    attack.     Its 
common  history  is  the  following,  and  we  may  take  as  an  illustrative  case 
a  male  aged  />().     The  patient,  who  is  of  full  habit,  short,  red-faced,  :md 
corpulent,  had  probably  led  a  rather  dissipated  life.     While  reading  his 
paper,  after  an  unusually  hearty  dinner,  he  suddenly  fell  to  the  floor  in  an 
unconscious  condition  ;  his   breathing  is  stertorous,  the  cheeks  and  lips 
being  puffed  out  by  each  expiration  ;  his  face  is  dark,  or  perhaps  very 
pale,  the  pupils  dilated  and  insensible  to  light,  and  his  eyeballs  are  fixed, 
turned  upward,  and  drawn  to  one  side.     If  the  nostril  be  tickled  no  reflex 
movements  follow,  and  the  same  is  the  case  if  the  soles  of  the  feet  be 
titillated.     He  is  limp,  and  lies  upon  the  floor  in  an  inanimate  heap ;  the 
pulse  will  be  found  to  be  hard  and  full,  but  not  very  rapid,  and  if  his  tem- 
perature be  taken  it  will  probably  not  exceed  97°,  or  perhaps  is  half  a 
degree  lower.     He  is  taken  up  and  placed  in  bed,  and  after  a  while  may 
make  some  slight  voluntary  movement  with  the  limbs  of  one  side  of  the 
body.     It  will  be  seen  that  the  others  are  without  power,  for  if  the  leg  or 
arm  of  the  paralyzed  side  be  lifted  and  released  it  will  fall  to  the  bed  as 


CEREBRAL    HEMORRHAGE.  85 

a  dead  weight.  After  an  hour  or  two,  tickling  of  the  sole  of  the  unaffected 
foot  will  be  followed  by  a  drawing  up  of  the  sound  leg.  The  eyes  are 
still  rolled  up  and  turned  away  from  the  paralyzed  side  of  the  body,  and 
the  edges  of  the  ii-ides  are  covered  by  the  inner  canthus  of  one  palpebral 
commissure,  and  by  the  outer  canthus  of  the  other.  The  eyeballs  may 
be  sometimes  slightly  agitated  by  a  feeble  movement  of  a  nystagmic 
character.  It  will  be  found,  on  removing  the  patient's  clothing,  that  he 
has  unconsciously  voided  his  urine  and  feces.  This  condition  may  last  for 
a  few  hours,  the  coma  remaining  profound,  and  the  temperature  rising  to 
103  to  105  degrees,  and  the  pulse  advancing,  when  death  takes  place ;  or 
it  may  be  followed  in  an  hour  or  two  by  slight  signs  of  returning  intelli- 
gence, an  increase  of  temperature,  say  to  100°,  with  slight  abatement  of 
the  regular  respiration,  disappearance  of  stertor,  and  the  unnatural  devia- 
tion of  the  eyes,  when  his  temperature  may  return  to  the  normal  standard, 
and  the  patient  so  far  recover  consciousness  as  to  be  able  to  recognize 
those  about  him,  and  express  himself  by  simple  words,  as  "yes"  or  "no." 
The  urine  has  to  be  drawn  for  a  day  or  two,  and  the  bed-pan  used,  as  the 
bladder  and  rectum  are  implicated. 

This  form  of  cerebral  hemorrhage  may  be  connected  with  an  epilepti- 
form  attack  in  the  beginning,  and  the  convulsion  may  be  either  confined 
to  one  side  or  be  general.  It  would  be  well,  before  going  further,  to  dwell 
upon  certain  elements  of  the  apoplectic  attack  and  analyze  the  symptoms. 

THE    PSYCHICAL    DISTURBANCES. 

Sudden  compression  of  the  cerebral  mass  is  always  attended  by  uncon- 
sciousness, but  it  is  a  curious  fact  that  slowly  developed  growths,  such  as 
large  tumors  or  abscesses,  seem  to  accommodate  themselves  to  the  sur- 
rounding tissues,  so  that  sometimes  no  loss  of  consciousness  occurs  what- 
ever. I  have  seen  a  large  abscess  occupying  an  extensive  tract  of  one 
hemisphere  without  producing  the  least  loss  of  consciousness.  The  large 
effusions  which  produce  unconsciousness  are,  in  the  opinion  of  Mr.  Hutch- 
inson,1  productive  of  the  psychical  condition,  by  inducing  anemia  of 
other  parts  through  sudden  pressure.  Small  clots  are  undoubtedly  pro- 
ductive of  suspended  consciousness,  by  cutting  off  either  a  large  vessel,  or 
by  injury  to  some  important  sensory  ganglion  at  the  base  of  the  brain,  such 
as  the  corpus  striatum. 

Consciousness  is  either  restored  through  the  re-establishment  of  the 
blood  supply  or  the  subsidence  of  shock,  except  where  the  hemorrhage 
has  taken  place  in  the  medulla.'8 

1  London  Hospital  Reports,  vol.  iv.,  1867. 

2  The  variation  in  the  loss  of  consciousness  is  of  great  importance  to  the  ph ysi- 
cian,  especially  in  regard  to  prognosis.     In  severe  cases  there  may  be  slight 
improvement  in   this   respect.      The   patient's   intelligence   returns   to  such  a 
degree  as  to  inspire  his  friends  with  some  degree  of  hope ;  but  there  is  often  a 
sudden  relapse  to  the  original  state  of  coma,  dependent  upon  fresh  hemorrhage. 


86  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

RESPIRATORY    DISTURBANCES. 

Stertor  is  an  important  symptom,  and  should  always  be  looked  upon 
with  alarm.  It  is  indicative  generally  of  some  lesion  of  the  base,  and 
nearly  always  lasts  until  death,  if  there  be  a  very  large  effusion,  but  dis- 
appears after  a  few  hours  if  recovery  is  to  take  place.  Respiration  under- 
goes very  decided  modification.  Hughlings  Jackson,1  in  speaking  of 
disturbed  respiration,  says :  "  Again,  not  only  is  the  rate  of  respiration  to 
be  considered,  but  the  character  of  the  respiratory  movements  are  to  be 
noted.  As  they  quicken  in  rate,  so  do  they  become  more  extensive  in 
range,  though  such  respiration  is  still  short.  Thus  in  the  first  stage  there 
may  be  only  quiet  action  of  the  diaphragm,  but  at  length  the  sides  of  the 
chest  evert  strongly  in  inspiration,  the  abdominal  movement  being  less 
obvious,  and  at  length  the  upper  thorax  takes  part  in  the  process.  In 
severe  cases  the  epigastrium  sinks  in  during  inspiration.  This  is  probably 
partly  owing  to  elevation  of  the  attachments  of  the  diaphragm  from  in- 
creased action  of  the  sides  of  the  thorax,  and  partly  to  pushing  down  of 
the  diaphragm  by  increasing  bulk  of  the  lungs  from  congestion  or  oedema." 

CONDITION    OF    THE    EYES. 

Prevost,8  Vulpian,  Lockhart  Clark,  and  others  were  among  the  first  to 
call  attention  to  a  peculiar  diagnostic  point  which,  though  not  always  pres- 
ent, is  of  great  value  when  it  occurs.  This  has  been  known  as  "  conjugate 
deviation."  During  the  apoplectic  condition  the  eyes  of  the  individual 
will  be  fixed,  so  that  they  look  upwards  and  outwards,  towards  the  side 
of  the  lesion,  and  away  from  the  paralyzed  side  of  the  body  ;  the  only 
exception  being  when  the  lesion  is  in  or  behind  the  pons.  It  is  more 
often  seen  when  the  attacks  are  sudden,  and  it  is  a  phenomenon  of  short 
duration,  Lasting  at  the  most  but  a  few  days.  During  sleep  the  condition 
subsides,  and  the  eyeballs  are  restored  to  their  normal  state,  but  imme- 
diately on  awaking  they  return  to  this  position,  and  in  spite  of  the  pa- 
tient's effort  the  axis  of  vision  cannot  be  changed.  When  the  effusion 
is  a  large  one,  or  when  the  onset  is  epileptiform,  the  pupils  are  at  first 
very  wildly  dilated ;  but  when  there  exists  a  lesion  in  the  pons  the  pupil 
which  corresponds  to  the  side  of  the  lesion  is  greatly  contracted.  Unequal 
dilatation,  however,  is  not  of  very  great  diagnostic  value.  If  a  lesion  in 
the  pons  be  extensive,  both  are  contracted. 

TEMPERATURE  AND  PULSE. 

Thanks  to  Bourneville,3  we  are  enabled  to  study  systematically  the 
variations  of  temperature.  He  divides  the  cases  into  four  groups:  1. 

1  Op.  cit.,  p.  548.  *  Gazette  Hebdom.,  Oct.  13,  1865. 

3  Etudes  cliniques  et  thcrmometriques  sur  les  Maladies  du  Systeme  nerveux, 
Paris,  1872. 


CEREBRAL    HEMORRHAGE.  87 

Copious  cerebral  hemorrhage,  rapidly  fatal,  and  attended  by  lowered  tem- 
perature. 2.  Cerebral  hemorrhage,  terminating  fatally  in  from  one  to  two 
days,  in  which  the  temperature  is  primarily  lowered  and  afterward  height- 
ened. 3.  Fatal  cases  in  which  death  takes  place  in  from  two  to  six  days. 
In  these,  as  in  other  forms,  there  is  at  first  depressed  temperature,  next  a 
return  to  the  normal  standard,  with  slight  variations,  and  finally  a  decided 
rise.  4.  Favorable  cases,  in  which  there  are  the  primary  lowering,  a  sec- 
ondary rise,  and  final  return  to  the  standard  of  health. 

These  variations  in  temperature  range  between  96  and  108  degrees 
Fahrenheit  (rectal  temperature).  ,The  pulse  variation  bears  but  slight 
relation  to  the  fluctuation  of  the  body  heat.  In  the  four  classes  spoken 
of,  we  may  consider  in  the  first,  that  the  pulse  is  full  and  slow,  ranging 
from  55  to  65.  With  the  rise  of  temperature  which  characterizes  the 
others,  it  becomes  greatly  accelerated,  beating  oftentimes  120  or  130  per 
minute,  losing  its  full  character,  and  becoming  small  and  irritable,  and  if 
death  occurs,  grows  gradually  weaker.  If  recovery  follows  the  attack, 
there  is  a  gradual  return  to  its  normal  rate.  Of  course,  this  must  be  a 
very  unsatisfactory  consideration  of  the  state  of  the  pulse,  for  the  apoplec- 
tic condition  is  not  always  the  same,  collapse  and  reaction  varying  greatly 
in  regard  to  their  occurrence  and  duration ;  so  the  pulse,  as  well  as  respira- 
tion and  temperature,  undergoes  many  irregular  modifications. 

ATTACKS  WITHOUT  LOSS  OF  CONSCIOUSNESS. 

The  other  form,  in  which  the  individual  preserves  his  consciousness,  is 
not  so  serious  a  condition  as  that  just  described.  The  person  may  present 
some  of  the  premonitory  symptoms  already  mentioned,  or,  on  the  other 
hand,  may  receive  no  warning,  but  while  engaged  in  any  ordinary  occu- 
pation may  suddenly  find  one-half  of  his  body  to  be  paralyzed,  and  be  un- 
able to  communicate  with  those  about  him,  there  being  slight  aphasia. 
With  the  paralysis  there  may  be  anaesthesia.  This  state  of  affairs  may 
begin  during  the  night,  and  on  awakening  in  the  morning  he  may  find  it 
impossible  to  leave  his  bed.  The  paralysis  is  sometimes  gradual,  the  loss 
of  power  affecting  one  member,  and  afterwards  the  other,  an  unexpected 
feebleness  being  suddenly  noticed  as  he  is  about  to  perform  some  act.  One 
of  my  patients,  an  acrobat  of  dissolute  habits,  while  preparing  for  the 
performance,  found,  when  he  attempted  to  put  on  his  tights,  that  his  right 
leg  was  quite  powerless ;  he  made  an  effort  to  stand,  but  became  dizzy, 
and  grasped  for  support  a  pole  that  was  near.  After  repeated  efforts  to 
dress  he  abandoned  the  attempt,  summoned  assistance,  and  was  taken 
home  ;  the  same  night  the  right  upper  extremity  was  affected.  He  had 
never  had  any  previous  warning.  Attacks  of  this  kind  may  be.  the  fore- 
runners of  others  of  a  more  serious  nature.  In  illustration,  may  be  men- 
tioned the  case  of  S.  C.,  a  married  woman,  aged  41.  She  was  drawing 
water  at  a  sink,  when  she  became  suddenly  giddy,  and  had  to  take  hold  of 
the  banisters  to  steady  herself.  She  stood  thus  until  some  friends  put 
her  into  a  chair  and  carried  her  to  her  room.  She  sat  there  that  day,  and 


88  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLI   M. 

was  helped  to  bed,  but  did  not  discover  her  paralysis  until  next  inorninjr. 
Was  not  unconscious  at  any  time  of  the  attack.  Her  paralysis,  when  -In- 
discovered  it,  was  somewhat  worse  than  it  is  at  present,  and  she  could  not 
speak  as  well  as  she  now  does.  A  few  days  after  the  attack  she  went  to 
a  hospital,  where  she  remained  one  month.  She  entered  the  Epileptic 
Hospital  July  6,  1875,  and  was  put  upon  strychnine  and  belladonna.,  then- 
existing  an  inability  to  retain  her  urine.  I  take  the  notes  of  her  subse- 
quent history  from  the  case-book  of  the  hospital. 

"  Sept.  22.  At  7.30  last  night  it  was  noticed  that  she  could  not  speak  as 
well  as  formerly.  It  was  quite  difficult  for  her  to  speak  so  as  to  be  under- 
stood. She  laughed  a  little  immoderately  at  her  inability  to  clearly  enun- 
ciate the  words. 

"  An  hour  afterwards,  in  attempting  to  leave  her  bed,  she  fell,  and  since 
then  has  been  scarcely  able  to  speak,  and  can  only  say  a  few  words.  No 
other  symptoms  were  noticed.  Her  strength  of  muscle  and  sensibility 
seem  unaffected.  She  cries  now  continually,  and  seems  to  be  depressed 
because  she  cannot  speak. 

"  Oct.  13.  Patient  can  tell  her  name,  and  can  name  every  article  shown 
her.  A  little  thickness  in  articulation. 

"  Pupils  react  well.  Lenses  of  eyes  are  a  little  opaque — the  left  a  little 
more  than  the  right.  Face  palsy  almost  passed  away.  Lower  facial 
muscles  act  well.  Sensibility  in  face  fair.  Tongue  points  slightly  to  the 
right. 

"  Voluntary  motion  abolished  in  right  upper  extremity,  the  least  motion 
in  shoulder  excepted.  Articulations  are  all  flexed  in  the  right  upper 
extremity,  and  the  contracture  is  greatest  in  the  hand,  the  fingers  almost 
touching  the  palm.  Elbow  and  shoulder  are  less  rigid. 

"  Extension  is  not  painful,  and  there  are  no  spontaneous  pains  in  arm. 
Sensibility  to  contact  in  hand  good.  On  finger  tips  feels  the  points  of 
jESthesiometer  at  three  millimetres.  There  is  no  numbness  in  hands.  Pa- 
tient considers  the  paralyzed  hand  the  warmer  of  the  two.  Between  index 
finger  and  middle  finger  of  right  hand  in  three  minutes'  time  the  tempera- 
ture is  98°.  Same  place  on  left  hand  in  three  minutes'  time  temperature 
is  98£°.  Right  lower  extremity,  no  motion  in  toes  and  ankles,  consider- 
able motion  in  knee  and  hips,  no  numbness,  no  contraction. 

"  An  interesting  feature  of  this  case  was  exaggerated  emotional  disturb- 
ance, which  is  usually  quite  marked  in  right  hemiplegia." 

THE    RESIDUAL    PARALYSIS. 

A  paralysis,  remaining  after  the  "  apoplectic  stroke,"  is  generally  uni- 
lateral, though  in  rare  cases,  where  the  pons  is  affected  at  the  central 
portion,  the  paralysis  may  exist  on  both  sides  of  the  body;  this  one-sided 
paralysis  is  known  as  Hemiplegia^  and  may  be  complete  or  incomplete  as 
regards  sensation  and  motion.  When  we  examine  our  patient  after  the 
immediate  grave  symptoms  have  to  some  degree  subsided,  we  will  find  the 
limbs  of  one  side  limp,  powerless,  and  generally  without  sensation  ;  the 


CEREBRAL    HEMORRHAGE.  89 

face  paralyzed  on  the  same  side,  and  its  other  half  drawn  up  by  the  healthy 
muscles,  as  their  antagonists  are  unable  to  perform  their  functions.  If  the 
patient  be  sensible  enough  to  put  out  his  tongue,  it  will  point  to  the  para- 
lyzed side,  while  the  eyes,  if  conjugate  deviation  exists,  will  turn  in  an 
opposite  direction  in  a  manner  already  described. 

Gastrowitz1  has  called  attention  to  a  peculiar  symptom,  the  tendency  of 
the  patient  to  slip  out  of  bed  on  the  unaffected  side.  This  is  caused  by 
the  inability  of  the  paralyzed  limb  to  support  the  weight  of  the  sound  part 
of  the  body.  He  also  alludes  to  the  fact,  when  pressure  is  made  on  the 
saphena  nerve,  at  the  point  where  the  vastus  externus  makes  a  groove  with 
the  vastus  internus,  that  the  cremaster  muscle  on  the  paralyzed  side  will 
not  draw  up  the  testicle,  which  is  not  the  case  on  the  other  side  of  the 
body.  In  other  forms  of  paralysis,  to  be  hereafter  described,  there  is  not 
the  same  uniformity  of  symptoms,  there  being  perhaps  paralysis  of  special 
cranial  nerves,  or  those  of  the  muscles  of  the  face  on  the  side  opposite  to 
the  body  paralysis.  This  variety  has  been  called  cross  paralysis.  Both 
sides  of  the  face  or  both  sides  of  the  body  may  be  involved,  in  which  event 
there  is  a  speedy  fatal  termination.  Occasionally  the  muscles  of  the 
pharynx  may  be  paralyzed,  and  sometimes  the  larynx.  A  case  of  this 
latter  kind  is  reported  by  Luys.2  He  mentions  the  case  of  "  a  woman  who 
had  a  sudden  attack  of  apoplexy  with  hemiplegia  of  the  left  side,  but  with 
no  disturbance  of  sensibility  or  of  the  organs  of  special  sense.  The  con- 
gestive phenomena  of  the  onset  being  calmed  little  by  little,  the  patient 
regained  consciousness,  and  stated  that  four  years  previously  she  had  been 
struck  for  the  first  time  with  left  hemiplegia,  and  since  then  had  been 
aphonic.  Her  intelligence  was  good,  and  she  spoke  distinctly,  but  in  a  low 
voice.  She  had  no  paralysis  of  the  tongue,  the  soft  palate,  or  the  lips.  A 
few  days  later,  she  was  seized  with  new  congestive  symptoms,  and  died 
insensible." 

This  laryngeal  paralysis  is  undoubtedly  a  much  more  common  affection 
than  it  is  generally  supposed  to  be,  and  the  probability  is  that  many  of 
the  cases  reported  as  aphasic  are  in  all  probability  simple  aphonia.  Our 
patient,  after  his  return  to  consciousness,  will  then  be  found  to  be  hemi- 
plegic,  and,  if  he  is  amused  and  attempts  to  laugh,  we  will  plainly  notice 
facial  distortion  which  follows  any  such  efforts.  The  surface  temperature 
of  the  paralyzed  parts  is  usually  higher  than  on  the  other  side,  and  the 
limbs  may  seem  to  be  of  greater  contour.  This  appearance  has  been 
noticed  by  Hitzig,3  who,  in  referring  to  Charcot's  cases,  presents  seven  of 
his  own,  in  all  of  which  there  was  incomplete  dislocation  of  the  head  of  the 
humerus,  with  irregular  pains  of  the  arm,  increased  by  pressure.  The 
paralyzed  arm  was  swollen,  warmer  and  more  moist  than  its  fellow,  and 
the  pains  alluded  to  began  about  six  weeks  after  the  apoplectic  attack. 

1  Berliner  Klin.  Woch.,  Aug.  2,  1875. 

2  La  France  M6dicale,  Sept.  28,  1875. 

3  Yirchow's  Archiv,  xlviii.  p.  345. 


90  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

Hitzig  is  of  the  opinion  that  this  condition  of  affairs  is  not  directly  de- 
pendent upon  the  central  lesion.  Voluntary  power  is  lost  in  proportion 
to  the  extent  and  situation  of  the  lesion.  Should  it  be  in  the  corpus  striu- 
tum,  a  very  small  lesion  may  produce  very  decided  impairment  of  motility, 
while  such  is  not  the  case  in  the  white  matter  of  the  hemispheres.  It  will 
generally  be  found  necessary  to  draw  the  patient's  urine  for  a  few  days, 
for  the  bladder  loses  its  expulsive  force,  and,  if  this  procedure  be  not  re- 
sorted to,  there  may  be  incontinence.  Electric  contractility  seems  to  be 
exaggerated  at  first  in  the  paralyzed  limbs,  and  a  very  weak  electric  cur- 
rent may  provoke  the  most  energetic  contractions.  In  certain  cases  there 
may  be  an  increase  of  reflex  excitability  and  tactile  sensibility.  Sensa- 
tions may  be  even  sometimes  reversed,  warmth  being  felt  as  cold,  or 
vice  versd,  or,  as  in  the  case  quoted  by  Bastian,1  a  warm  object  may  be 
appreciated  as  a  weight.  "  A  hot  body  on  the  face  was  recognized  as 
pressure  only ;  on  the  arm  it  was  felt  as  such,  though  the  sensation  was 
not  distinctly  localized,  whilst  on  the  left  leg  the  same  hot  body  was  recog- 
nized correctly  as  regards  situation,  though  it  gave  rise  only  to  a  feeling 
of  tingling."  I  have  often  witnessed  hyperaesthesia  of  the  paralyzed  limbs, 
which  were  often  very  tender  to  the  touch.  Anaesthesia  generally  exists, 
however,  and  electro-sensibility  is  greatly  diminished.  At  the  end  of  a 
few  days  it  is  not  uncommon  to  find  marked  rigidity  of  the  paralyzed 
limbs,  increased  reflex  excitability,  and  other  evidences  of  slight  cerebritis 
at  the  seat  of  the  clot.  Gradually  there  is  a  return  to  the  normal  condi- 
tion, and  articulation,  which  was  imperfect  in  the  beginning,  may  become 
more  distinct,  or,  should  there  be  aphasia,  the  patient  will  begin  to  com- 
mand a  greater  number  of  expressions.  A  week  or  so  passes,  and  he  is 
able  to  protrude  his  tongue  in  a  much  straighter  line  than  before,  while 
the  paralyzed  muscles  of  the  face  slowly  recover  their  lost  power ;  but 
when  the  levator  palpebrae  is  paralyzed  and  ptosis  results,  restoration  is 
much  more  slow.  In  regard  to  this  paralysis,  Bastian  has  reminded  us 
that  very  often  deformities  exist,  such  as  the  absence  of  teeth  on  one  side, 
which  may  produce  an  appearance  of  facial  paralysis,  when  in  reality  none 
exists.  This  is  seemingly  a  trivial  matter,  but  its  neglect  is  likely  to  lead 
to  grave  errors  in  diagnosis  and  prognosis.  As  months  go  by,  gradual 
amelioration  of  the  patient's  condition  takes  place,  the  limbs  regain  their 
power,  the  leg  first,  and  finally  the  arm,  and  the  patient  may  be  at  first 
able  to  move  his  toes,  then  to  raise  his  leg,  and,  when  he  leaves  his  bed, 
gradually  begins  to  acquire  power  of  locomotion.  The  walk  of  the  hemi- 
plegic  is  not  to  be  mistaken ;  his  gait  is  shuffling,  the  toe  of  the  boot  is 
dragged  over  the  ground,  and  the  leg  thrown  outwards  and  forwards,  the 
knee  being  stiff,  and  the  arm  is  swung  helplessly  by  the  side.  As  the  gait 
improves,  and  the  patient  gains  more  control  over  his  limbs,  he  is  able  to 
perform  "movements  which  require  the  action  of  the  muscles  of  the  hip- 
joint,  knee-joint,  and  finally  the  ankle  and  toes.  Should  the  patient  only 

1  Op.  cit.,  p.  128. 


CEREBRAL    HEMORRHAGE.  91 

partially  recover,  numerous  secondary  conditions  may  follow,  as  results  of 
non -improvement  of  the  cerebral  condition.  These  are  chiefly  of  a  moto- 
rial  character,  and  consist  of  spasms,  permanent  contractures,  atrophy, 
and  inflammations  of  nerve-trunks.  Such  sequela  may  be  called 


THE  POST-PARALYTIC  STATES. 

T  may  enumerate  these  as — 1.  Permanent  contractures;  2.  Trophic 
alterations ;  3.  Tremor  (post-paralytic  chorea  of  Mitchell  and  Charcot)  ; 
and,  4.  Slow  clonic  spasms  (atheotosis  of  Hammond). 

Of  32  cases  of  old  hemiplegia  seen  by  Bouchard1  at  La  Salpetriere,  in 
31  there  were  paralytic  contractures.  The  other  case  presented  what  he 
called  I'hemiplegie  flasque.  This  form  is  of  slow  appearance,  and  affected 
in  the  beginning  the  muscles  of  the  forearm.  The  fingers  were  flexed,  and 
the  forearm  was  pronated  and  flexed  on  the  arm,  and  at  the  same  time  the 
humerus  was  drawn  to  the  trunk. 

According  to  Strauss,8  this  form  presents  several  variations,  and  some- 
times the  hand  is  brought  in  contact  with  the  trunk,  either  on  its  palmar, 
dorsal,  or  radial  aspects.  Of  a  large  number  of  cases  that  have  come 
under  my  observation,  I  have  found  that  deformities  of  the  upper  extremi- 
ties are  much  more  common  than  of  the  lower;  the  fingers  are  commonly 
flexed  arid  rarely  extended,  while  the  muscles  of  the  trunk  seem  to  be 
exempt  from  this  change ;  and,  indeed,  I  cannot  call  to  mind  a  single  in- 
stance of  this  kind.  Contractures  of  the  muscles  of  the  lower  extremities 
are  apt  to  produce  deformities  which  resemble  talipes,  equinus  varus  or 
valgus,  and  the  toes  are  flexed  upon  the  sole.  Contractures  of  the  facial 
muscles  are  quite  rare,  and  of  late  appearance.  The  deformities  are 
always  quite  striking,  because  of  the  antagonistic  action  of  unaffected  mus- 
cles, and  usually  no  amount  of  force  can  overcome  them.  Trophic  changes 
are  by  no  means  rare,  either  in  connection  with  contractured  muscles  or 
alone.  I  have  now  several  patients  under  observation  who  are  hemiplegic. 
In  one  of  these  the  skin  of  the  paralyzed  hand  is  white  and  puffed  up  ;  the 
heads  of  the  phalanges  and  metacarpal  bones  are  reduced  in  size,  so  that 
there  is  no  enlargement  at  their  points  of  articulation,  and  a  consequent 
depression  exists.  In  other  cases  there  is  considerable  muscular  atrophy 
to  be  witnessed  in  the  palm  of  the  hand ;  and  in  others,  the  bones  of  the 
arm  are  greatly  diminished  in  size,  and  the  interossei  quite  wasted  away. 

Charcot3  has  written  extensively  about  a  form  of  neuritis  following 
cerebral  lesions,  which  is  supposed  to  be  of  a  central  nature.  That  ascend- 
ing (from  the  periphery  to  the  centre)  neuritis  sometimes  takes  place  after 
cerebral  hemorrhage  there  can  be  no  manner  of  doubt ;  and  in  one  case, 
at  present  under  observation,  the  neuritis  began  at  several  different  peri- 

1  Strauss,  des  Contractures,  Paris,  1875,  p.  16.  *  Op.  fit. 

3  Legons  sur  les  Maladies,  etc.     Fasc.  1,  and  previous  articles. 


92  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

phcral  points  of  the  nerve,  and  there  were  consequent  atrophic  muscular 
changes.' 

Various  irregular  movements  of  partially  paralyzed  limbs  are  by  no 
means  uncommon.  Dr.  Gowers'  presents  the  following  excellent  table, 
which  embraces  all  the  disturbances  of  motility  which  may  occur  after  the 
hemiplegic  attack. 

POST-HEMIPLEGIA  DISORDERS  OF  MOVEMENT. 

(   Fine. 
f  Tremor       < 

I  Coarse. 
f  Regular  (continuous,  or  on  movement)  J 

|   Certain,   regular    move- 
ments due    to   interos- 


Un'rk.  rlonic  spasm,  of 


sei,  pronators,  etc. 


intermitting  type; 

Choreoid     C  Continuous 
I     spasm,  or 

L  Regular  (continuous,  or  on  movement)   •{  -{     inro-ordi- 

|      nation  of 
•L  Jerking      I,    movement. 

I*  Continuous  =»  ;<  Athetosis" 
SI  >w,  mobile  spasm,  of 
remitting  type  ]    On  movement  =  slow,  cramp-like  inco-    1 

t      ordination  !   "  Spastic  contracture"  of 

I       hemiplegic  children. 
Tonic  spasm,  varying  f  Of  interossei,  conspicuous  j 

Fixed  rigidity,  unvarying    (.  Of  flexor  longus  digitorum,  conspicuous  =*  late  rigidity. 

The  will  does  not  always  retain  its  control  over  the  affected  muscles, 
though  voluntary  power  exists  usually  to  a  variable  extent,  and  the  motor 
troubles  are  generally  unilateral ;  still  there  are  rare  exceptions.  The 
influence  of  the  will  generally  increases  spasmodic  movements.  Spasms 
and  tremor  affect  first  the  smaller  muscles,  while  tonic  spasms  affect  the 
larger  muscles  of  the  limbs.  One  form  of  tremor  of  a  post-hemiplegic 
character  has  been  called  by  Mitchell  "post-paralytic  chorea;"  the  tre- 
mor is  suggestive  of  sclerosis,  and  may  begin  within  a  period  ranging 
from  one  to  several  months,  affecting  generally  the  upper  extremities.  It 
is  aggravated  by  any  exercise  of  volition.  It  may  affect  both  extremities, 
but  very  randy  the  face,  and  the  movements  are  quite  coarse,  and  may  be 
associated  with  a  certain  amount  of  hcmi-ansesthesia.  A  variety  of  move- 
ment of  a  clearly  post-hemiplegic  character  has  been  elevated  to  a  distinct 
position,  and  given  the  name  "  atheotosis"  by  Hammond.  As  this  con- 


1  Those  trophic  changes  are  of  a  most  interesting  nature.     Duncan*  found  in 
one  case  that  an  eruption  had  appeared  on  the  thigh  of  the  paralyzed  side  which 
disappeared  with  the  return  of  power ;  and  Charcotf  and  PayneJ  another.     In 
a  ease  mentioned  by  the  former,  a  vesicular  eruption  appeared,  which  followed 
the  distribution  of  the  superficial  ramifications  of  the  peroneal  nerve,  and  was 
coincident  with  the  hemiplegia.     In  this  ease  the  hemiplegia  followed  embolism, 
and  a  branch  of  a  spinal  artery  (rami  medulla;  spinales,  of  Rlidingcr)  was  found 
obstructed  by  a  plug.       Pressure  had  been  made  on   the  spinal  ganglion  from 
which  one  of  the  branches  of  the  sciatic  originates. 

o 

2  Med.  Chir.  Trans.,  vol.  lix. 


*  Journ.  of  Cutaneous  Med.,  Oct.  1868,  p.  69  ;  quoted  by  Charcot. 

t  Op.  cit.,  p.  72.  J  Br.  Med.  Journ.,  Aug.  1871. 


CEREBRAL    HEMORRHAGE.  93 

dition  is  ordinarily  a  secondary  affection  to  other  neuroses  as  well  as 
hemiplegia,  the  undue  prominence  which  it  has  received  is  entirely  unde- 
served. Gowers  says :  "  Neither  clinical  history  nor  supposed  pathology 
of  atheotosis  affords  ground  for  separating  it  from  other  forms  of  disordered 
movement  commonly  seen  after  hemiplegia,  but  any  one  of  which  might 
occur  in  the  primary  affection."  Charcot1  refuses  to  acknowledge  its  dis- 
tinct character.  He  presents  several  cases,  all  of  which  followed  some 
form  of  hemiplegia  ;  and  the  literature  of  neurology  is  replete  with  exam- 
ples of  so-called  atheotosis  which  are  generally  connected  with  hemiplegia, 
chorea,  or  even  hysteria.  I  have  myself  seen  a  case  of  the  latter  kind 
which  disappeared  spontaneously  in  a  few  weeks  after  its  appearance. 
This  form  of  movement  is  considered  by  Hammond  to  consist  of  a  spas- 
modic agitation  of  the  fingers,  and  is  "characterized  by  an  inability  to  re- 
tain the  fingers  and  toes  in  any  position  in  which  they  may  be  placed,  and 
by  their  continual  motion." 

The  following  case  is  one  of  post-paralytic  chorea,  connected  probably 
with  embolism,  and  with  a  certain  amount  of  neuritis  of  a  very  painful 
character : — 

Jane  C..  35  ;  Ireland ;  single ;  domestic.  Entered  hospital  May  22, 
1876.  Family  history  good,  as  far  as  known  by  the  patient.  She  states 
that  her  health  has  always  been  good,  with  the  exception  of  an  attack  of 
rheumatism  a  year  ago.  Two  weeks  ago,  while  dressing,  she  fell,  and 
thinks  that  she  remained  unconscious  for  eight  minutes.  On  recovery  she 
was  unable  to  use  her  right  hand  or  leg,  and  was  placed  in  bed,  where  she 
remained  for  seven  days.  She  vomited  everything  taken  into  the  stomach. 
She  was  brought  to  the  hospital  a  few  days  ago,  suffering  from  paralysis 
of  the  right  side,  which  was  complete  and  affected  both  limbs.  There  was 
some  rigidity,  decided  headache,  and  paralysis  of  the  muscles  supplied  by 
the  portfeGMlura  upon  the  right  side.  She  was  intensely  emotional,  and 
moaned  and  cried. 

July  12.  Patient  has  been  quite  sick  for  the  past  four  weeks.  There 
have  been  high  evening  temperature,  abdominal  tenderness,  diarrhoea,  and 
other  evidences  of  typhoid  fever.  She  has  been  kept  on  milk  diet,  with 
quinia  and  stimulants. 

Aug.  18.  Patient  has  improved  somewhat.  She  is  very  weak,  but  able 
to  go  about  the  ward.  The  hand  and  forearm  of  the  right  side  are  rather 
rigid,  and  the  fingers  are  flexed,  but  it  is  possible  to  extend  them.  Pa- 
tient still  emotional,  and  cries  readily  when  excited.  There  is  decided 
tremulousness  of  this  extremity.  Pain  in  the  shoulder,  which  shoots  down 
the  arm.  These  pains  are  more  intense  at  night.  Aphasia  disappears. 

Nov.  23.  The  patient's  hand  shakes  whenever  any  voluntary  movement 
is  made.  She  cannot  feed  herself,  for  when  she  takes  up  her  fork  or  spoon 
she  cannot  carry  food  to  her  mouth.  The  pains  are  still  severe,  and  seem 
centered  more  in  the  shoulder.  She  can  move  her  right  arm  nearly  as 
well  as  the  left,  but  cannot  hold  any  large  object  placed  therein.  Exami- 
nation of  heart  revealed  a  heart  murmur,  with  second  sound  heard  with 
greatest  intensity  over  aortic  valves,  and  not  transmitted  in  either  direc- 
tion. A  murmur  is  also  heard  with  first  sound,  which  is  transmitted  into 
the  carotids.  There  are  probably  both  aortic  stenosis  and  insufficiency. 

1  Op.  eit.,  4th  part,  p.  455. 


94  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

Oct.  1877.  The  patient  is  still  in  the  hospital.  Complains  now  of  dix- 
ziness  and  disordered  vision,  which  is  not  dependent  upon  any  structural 
alteration.  The  right  arm  and  hand  are  much  more  quiet  than  they  have 
been.  There  is  very  little  of  the  tremor  which  was  at  h'rst  coarse,  but 
rhythmical.  She  can  now  execute  a  variety  of  acts,  but  an  especially 
delicate  operation  is  attended  with  aggravation  of  the  tremor. 

Causes Any  agency  which  favors  a  degeneration  of  cerebral  vessels 

leads  to  the  occurrence  of  hemorrhage  such  as  I  have  just  described.  The 
list  of  such  causes  is  therefore  a  long  one.  Among  the  many  formidable 
diseases,  leading  to  that  which  forms  the  subject  of  our  remarks,  are  those 
of  the  heart  and  kidneys.  Hypertrophy  of  the  left  ventricle,  Bright's 
disease,  and  local  disease  of  the  arteries  with  deposits  of  atheromatous  mat- 
ter, or  obliteration  of  vessels  by  softening,  pressure  made  by  tumors,  and 
through  other  diseases  of  the  brain,  may  be  mentioned  as  influencing  the 
causation  of  cerebral  hemorrhage.  Cerebral  hemorrhage  is  an  affection  of 
advanced  life,  though  cases  are  on  record  among  children.  A  careful 
inspection  of  the  records  of  a  great  many  cases  discloses  the  fact  that  the 
majority  are  between  fifty  and  sixty.  With  the  advance  of  life  and  cor- 
responding impairment  of  vitality,  the  arteries  become  rigid,  the  heart  hy- 
pertrophied,  and  the  general  vascular  system  undergoes  important  changes. 
I  have  already  alluded  to  the  annular  and  hard  character  of  the  arteries ; 
the  arcus  senilis,  which  consists  of  a  small  whitish  circle  which  may  be  seen 
overspreading  the  iris,  may  be  mentioned  in  addition  as  a  suggestive  sign. 
The  color  of  the  face  is  dusky  red,  and  many  of  the  capillaries  of  the  skin 
covering  the  cheeks  and  nose  are  quite  tortuous  and  dilated,  and  present 
minute  varicose  enlargements.  As  to  inheritance  of  an  apoplectic  ten- 
dency, I  fully  agree  with  Hughlings  Jackson,  that  the  only  heritage  trans- 
mitted from  father  to  son  is  the  liability  to  arterial  degeneration,  gout,  etc. 
This  exception  to  the  general  rule  is  somewhat  conspicuous,  for  the  here- 
dition  of  many  convulsive  and  neuralgic,  as  well  as  the  trophic  diseases, 
is  a  well-established  fact,  and  has  long  been  recognized  as  an  important 
etiological  factor.  Cerebral  hemorrhage,  as  I  have  stated,  is  by  no  means 
confined  exclusively  to  adult  life.  Numerous  observers  have  called  atten- 
tion to  cases  which  have  occurred  among  very  young  children,  though, 
in  these  instances,  injury  has  generally  produced  the  accident,  especially 
such  mechanical  causes  as  convulsions,  anremia,  etc.  And  now  regarding 
the  predisposing  states  which  favor  the  rupture  of  a  vessel.  An  hypertro- 
phied  heart,  enlarged  by  overwork  in  forcing  the  overloaded  blood  which 
must  be  formed  when  the  kidneys  do  not  properly  act  as  eliminants,  is  the 
first  factor  of  the  disease.  With  this  condition  of  affairs  the  small  vessels 
must  necessarily  be  subjected  to  abnormal  strain,  and  consequently  under- 
go such  changes  as  thickening  or  aneurismal  dilatation,  or  even  actual 
destruction.  The  arterial  changes,  of  which  I  will  more  fully  speak  when 
we  come  to  consider  the  pathology  of  the  disease,  are  fatty  degeneration, 
aneurismal  dilatation,  and  calcification.  These  conditions  are  produced 
by  alcohol,  and  improper  diet,  such  as  continued  indulgence  in  fatty  food. 
A  sedentary  life,  connected  with  great  and  protracted  intellectual  strain, 


CEREBRAL    HEMORRHAGE.  95 

as  well  as  such  diseases  as  rheumatism,  syphilis,  and  other  chronic  mala- 
dies, enter  the  field  as  predisposing  causes.  Season  appears  to  have  some 
influence  in  the  production  of  cerebral  hemorrhage,  the  majority  of 
cases  occurring  in  winter.  As  to  exciting  causes,  their  name  is  Legion. 
Straining  at  stool,  coition,  violent  muscular  effort  of  any  kind,  the  indul- 
gence in  stimulants,  and  in  fact  any  agency  which  either  promotes  an  ab- 
normal blood  supply  to  the  brain,  or  prevents  its  return,  will  have  the 
effect,  should  there  be  disease  of  the  vessels,  of  producing  rupture.  I 
have  taken  from  my  case-book  data  showing  the  exciting  causes  in  a  num- 
ber of  cases,  and  the  time  of  the  attack  : — 

Lifting  a  heavy  weight,  or  other  muscular  effort      .  12 

Excitement  (alarm  of  fire)     .....  1 

Drawing  water       .......  1 

Falls 4 

Fright  .........  3 

Thrown  down  by  husband      .....  1 

Head  injuries          .......  8 

Straining  at  stool  .......  2 

No  history  of  cause 20 

52 

Time  of  Attack. — At  night,  in  30  cases;  during  the  day,  in  22  cases. 

The  fact  that  the  large  proportion  of  these  attacks  occur  at  night,  is  an 
interesting  one.  They  were  mostly  hospital  patients,  and  some  were  irre- 
sponsible ;  so,  of  course,  their  statements  are  to  be  taken  with  allowance. 
One  woman  said :  "  I  awoke  in  a  fright,  and  in  attempting  to  rise  found 
I  was  unable  to  do  so."  It  is  probable,  therefore,  that  the  condition  was 
dependent  upon  disturbed  cerebral  circulation  connected  with  nightmare; 
but  in  opposition  to  Hammond's  statement  that  the  occurrence  of  the  hem- 
orrhage during  "  healthy,  undisturbed  sleep"  is  unlikely,  I  will  state  that 
nearly  every  one  of  these  thirty  patients  found  that  they  were  paralyzed 
only  when  they  awoke  in  the  morning,  and  attempted  to  get  out  of  bed. 
Exposure  to  the  sun's  rays,  and  the  stoppage  of  any  flux  that  is  either 
normal  or  pathological,  are  often  sufficient  to  produce  an  attack,  and  as  an 
example  of  the  latter  hemorrhoidal  bleeding  may  be  mentioned. 

Heiniplegia  may  be  a  result  of  variola  ;  and  the  following  case,  in  which 
epilepsy  and  hemiplegia  dated  from  smallpox,  possesses  much  interest. 
The  paralysis  was  due  undoubtedly  to  an  epileptic  seizure,  during  which 
some  vessel  was  ruptured. 

M.  J.  T.,  35  years,  born  in  New  York ;  no  occupation  ;  entered  the 
Epileptic  and  Paralytic  Hospital  Feb.  11,  1870.  Mother  died  of  con- 
sumption ;  sister  had  epilepsy.  First  fits  appeared  at  the  age  of  five  years  ; 
came  on  about  three  months  after  an  attack  of  smallpox  ;  hemiplegia  of 
the  right  side  came  on  at  the  same  time,  she  believes,  as  the  epilepsy. 
Before  the  convulsions  she  has  cramps  in  the  paralyzed  arm  and  hand,  and 
a  feeling  of  dizziness  ;  the  attacks  occur  most  frequently  in  the  daytime, 
three  or  four  together,  and  recur  once  in  three  or  four  weeks.  But  shortly 


96  DISEASES    OP    THE    CEREBRUM    AND    CEREBELLUM. 

before  her  admission  she  had  them  nearly  every  day.  Circumference  of 
skull,  20|  inches;  antero-posterior  measurement,  13  inches;  transverse, 
13  inches;  memory  good,  mind  rather  weak;  speech  good,  sight  good, 
hearing  fair  with  left  ear;  cannot  hear  with  right  ear,  even  when  the 
watch  is  pressed  against  it.  Sensibility  to  pinching  and  pi-irking  appeal- 
entirely  abolished  on  the  right  side  from  head  to  foot.  Drags  right  leg  in 
walking ;  has  but  little  use  of  right  arm  and  hand,  the  muscles  of  which 
have  a  tendency  to  spasmodic  contraction  ;  temperature  somewhat  dimin- 
ished on  right  side  ;  appetite  fair  ;  bowels  rather  costive.  Menstruated  at 
*3  years,  and  has  been  regular  since. 

Present  condition,  June  1,  1870  : — 

Memory  appears  to  be  very  good;  the  fits  have  decreased  in  severity 
and  in  number.  Had  but  two  attacks  last  month  ;  none  at  night.  Has 
ha'inoptysis  sometimes  before  the  attack,  and  an  aura  of  about  a  minute's 
duration  ;  flexor  of  muscles  of  right  hand  is  contracted  ;  thumb  is  turned 
again,  so  that  its  inner  part  touches  the  under  part  of  the  index  finger ; 
lastly,  the  whole  hand  is  somewhat  drawn  up,  and  lies  in  her  lap  with  the 
palmar  surface  up.  When  directed  to  put  hand  up  to  shoulder,  it  shakes 
right  and  left ;  this  shaking  is  very  violent,  but  only  so  when  she  makes 
voluntary  movement.  It  is,  however,  entirely  quiet  while  in  her  lap. 
Has  the  irregular  hemiplegic  gait ;  protrudes  her  tongue  straight ;  eyesight 
good  ;  hears  perfectly  well.  There  is  facial  paralysis  (peripheral)  on  the 
side  opposite  the  hemiplegia,  but  no  ptosis.1 

Morbid  Anatomy  and  Pathology — A  vessel  impaired  by  dis- 
ease, and  subjected  to  even  the  normal  blood  pressure,  will  very  soon 
suffer  changes  in  its  calibre,  insignificant  perhaps  at  first,  but  afterwards 
far  more  serious.  But,  when  the  blood  pressure  is  abnormal,  and  a  force 
is  exerted  which  the  resilient  character  of  the  vessels  enables  them  to 
withstand  in  the  healthy  state,  the  weakened  portion  gives  way,  and  the 
brain-substance  in  the  neighborhood  is  subjected  to  dangerous  pressure. 
The  character  of  the  loss  of  function  depends  very  much  upon  the  import- 
ance of  the  vessels  and  their  areas  of  distribution.  The  middle  cerebral 
artery  is  especially  liable  to  rupture,  being  in  direct  communication  with 
the  left  side  of  the  heart;  consequently,  the  corpus  striatum,  optic  thalatnus, 
and  parts  supplied  by  this  artery,  suffer  injury.  The  other  large  vessels 
follow  next,  and  may  be  affected  in  various  parts  of  their  course.  The 
diagram  I  present  (Fig.  12)  illustrates  the  topography  of  brain-lesions,  and 
will  enable  the  reader  to  see  how  certain  hemorrhage  may  destroy  the  func- 
tion of  various  important  nervous  tracts,  the  symptoms  being  displayed 
generally  on  the  opposite  side  of  the  body,  but  occasionally  on  the  same. 
In  our  future  study  of  the  localization  of  lesions,  we  are  to  bear  in  mind 
the  physiological  experiments  of  Broca  and  Brown-Sequard,  and  the  later 

'  As  an  illustration  of  a  curious  cause,  Eulcnburg*  relates  the  case  of  a  switch- 
U'tider  who,  during  a  heavy  thunder  storm,  inserted  an  iron  key  in  the  lock  of  a 
switch-signal.  lie  was  suddenly  deprived  of  power,  and  fell  to  the  ground. 
After  an  hour  or  two,  when  sufficiently  revived  by  the  rain,  he  dragged  himself 
to  a  neighboring  station.  He  was  paralyzed  on  the  left  side. 

*  Berliner  Klin.  Woch.,  April  26,  1875. 


CEREBRAL    HEMORRHAGE.  97 

researches  of  Hughlings  Jackson,  Fritsch  and  Hitzig,  Vulpian,  Vesseyer, 
Ferrier,  Dupuy,  Pierret,  Raymond,  Putnam,  Carvaille  and  Duret,  and 
others.  The  pathological  course  of  cerebral  hemorrhage  is  the  following  : 
1.  The  stage  of  preparation,  during  which  the  arteries  undergo  the  changes 

Fig.  12. 


A.  Region  of  articulate  speech  (probably,  also,  slightly  developed  on  right  side  as  well). 
B  B.  Supra-ventricular  region  :  Paralysis  on  side  opposite  lesion.  As  a  rule,  not  as  susceptible 
to  dangerous  injury  as  parts  beneath.  C.  Ventricular  region  :  Lesions  apt  to  be  followed  by  serious 
motorial  and  sensorial  symptoms.  D.  Sub-ventricular  region  :  Lesions  apt  to  paoduce  paralysis 
of  cranial  nerves  by  extension  of  pressure.  1.  Lesion  in  central  part  of  hemisphere.  2  2.  Cortical 
lesion,  usually  affecting  special  motor  centres,  or  affecting  mental  functions.  3.  Lesion  affecting 
speech-centre.  4.  Lesion  affecting  nucleus  caudatus  of  corpus  striatum.  5.  Lesion  affecting  crus. 
6.  Lesion  affecting  peduncular  expansion.  7.  Lesion  affecting  centre  of  pons.  8.  Lesion  affecting 
lateral  half  of  pons.  9.  Lesion  affecting  medulla. 

already  spoken  of.  2.  The  operation  of  an  exciting  cause,  the  rupture  of 
the  vessel,  the  injury  of  the  nervous  substance,  and  the  formation  of  the 
clot.  3.  Death,  absorption,  or  limitation. 

Bouchard1  and  Charcot  both  affirm  that  cerebral  hemorrhage  is  always 
dependent  upon  a  peculiar  kind  of  disease  of  the  vessels.  This  diseased 
condition  consists  of  a  studding  over  with  minute  aneurismal  dilatations 
which  have  been  called  by  them  "miliary  aneurisms."  These  arise  from 
a  primary  degeneration  of  the  outer  coat  of  the  vessel,  generally  secondary 
sclerosis,  and  finally  atrophy  of  the  muscular  coat  and  dilatation.  Of 
sixty-five  cases  of  cerebral  hemorrhage,  they  found  miliary  aneurism  in 
every  instance.  Botli  of  these  authors  consider  the  vascular  change  to  be 
different  from  that  of  atheroma,  which  begins  in  the  inner  coat.  These 
appearances  are  confined  to  the  brain,  and  exist  when  there  is  no  evidence 
of  atheroma  to  be  found  in  any  other  part  of  the  body.  Notwithstanding 
that  these  views  are  endorsed  by  such  men  as  Meynert,  Bastian,  and  oth- 
ers, there  are  many  observers  who  consider  miliary  aneurisms  to  be  due 
only  to  careless  manipulation,  or  that  they  are  identical  with  the  "hyaline 


1   Arc-hives  des  Phvsiol.,  1868. 


98  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

degeneration"  of  Gull  and  Sutton  which  is  found  in  other  localities.1 
These  miliary  aneurisms  have  been  said  to  be  due  to  "  periarteritis,"  but 
it  cannot  be  denied  that  a  large  proportion  of  cases  of  renal  and  heart 
disease  produce  modifications  in  blood  pressure,  which  would  account  for 
the  rupture  of  the  vessel  without  any  primary  inflammatory  condition. 

Fig.  13. 


Miliary  Aneurisms. 


1  have  repeatedly  seen  miliary  aneurisms,  and  must  confess  that  they 
appeared  to  depend  upon  some  organic  change  which  extended  over  a  con- 
siderable space  of  time. 


1  Dr.  Barlow*  has  presented  a  case  which  fully  demonstrates  that  cerebral  em- 
bolism may  produce  a  condition  of  the  vessels  which  leads  to  the  formation  of  aneu- 
risms, first  causing  local  arteritis  and  weakening  of  the  wall  of  the  vessel.  In 
this  case  (that  of  a  boy  aged  ten  years)  there  was  right  and  afterwards  left 
hemiplegia,  and  aortic  regurgitation.  The  autopsy  revealed  "cortical  soften- 
ing on  each  side  of  the  lower  part  of  the  ascending  frontal  and  the  posterior 
parts  of  the  second  and  third  frontal  convolutions.  The  clue  to  this  condition 
was  found  in  the  middle  cerebral  arteries.  On  both  sides  these  vessels  were  dis- 
eased at  the  spot  where  the  fine  branches  were  given  off  over  the  island  of  Reil 
for  the  supply  of  the  cortex.  Of  these  branches  on  both  sides,  the  one  supplying 
Broca's  convolution  and  the  one  supplying  the  ascending  frontal  were  also  dis- 
eased. There  was  no  aneurism  to  be  discovered  anywhere,  but  the  walls  of  these 
vessels  presented  many  small  calcified  nodules  obvious  to  touch  and  sight."  This 
calcification  was  not  noticed  in  any  other  vessel  in  the  body,  and  emboli  had 
lodged  in  the  spleen  and  kidneys.  In  Goodhart's  cases  actual  aneurism  had  fol- 
lowed the  embolism,  and  Dr.  Barlow's  case  demonstrates  that  there  is  a  primary 
weakening. 

Durand-Fardelf  found  that  of  32  cases  the  arteries  were  only  healthy  in  9 
cases,  while  in  21  they  were  thickened,  and  in  2  ossified. 

AmlralJ  found  that  of  32  cases  the  arteries  were  apparently  healthy  in  but  4. 

*  Brit.  Med.  Journal,  April  7, 1877,  p.  362. 

\  Trait^,  clluique  et  pratique,  des  Maladies  des  Vieillards,  Paris,  1854,  p.  228. 

J  Clinique  Mid.,  vol.  v. 


CEREBKAL    HEMORRHAGE.  99 

Zenker  differs  from  Charcot  and  Bouchard,  and  considers  the  internal 
coat  to  be  that  which  is  first  attacked.  When  miliary  aneurism  exists,  it 
is  generally  in  conjunction  with  either  gout,  cancer,  tubercule,  leucocythe- 
mia,  or  other  conditions,  when  leucocytes  may  pass  into  the  cerebral  ves- 
sels in  large  number.  In  old  drunkards  and  general  paralytics  this  vascular 
change  is  not  an  uncommon  one.  In  regard  to  atheroma  there  have  been 
many  cases  brought  forward  where  this  appearance  was  so  constant  as  to 
gain  recognition  as  one  of  the  chief  factors  of  the  cerebral  hemorrhage.  An 
atheromatous  artery  contains  deposits  of  a  firm,  semi-fatty  nature,  between 
its  inner  and  middle  coats.  At  an  advanced  stage  the  deposit  is  more 
calcareous  and  hard,  and  the  artery  may  be  sometimes  easily  broken  in 
two.  Occasionally  the  deposit  between  the  coats,  by  distension  considera- 
bly narrows  the  calibre  of  the  vessel,  and  in  this  way  forms  occlusion  at 
one  point  while  at  a  weaker  one  hemorrhage  takes  place.  The  veins  and 
capillaries  are  not  so  often  involved  as  the  arteries.  In  regard  to  the  seat 
of  cerebral  hemorrhages,  we  find  from  a  table  prepared  by  Gintrac  that  in 
751  cases  there  was — 

Times. 
Hemorrhage  in  the  meninges       .         .         .         .         '.         .         .172 

"  "       middle  lobes  . '  .         .         .         .     127 

"  "       pons  and  peduncle          .         .         .         .         .76 

"  "       corpora  striata        .         .         .         .         .         .72 

cerebellum     .......       55 


corp.  striata  and  op.  thai 48 

ventricles  (septum  and  plexus)        ...  46 

cortex             .......  45 

op.  thalami    .......  38 

post,  lobes     ....  33 

ant.  lobes      .         .         .         •         •         •         .17 

corpus  callosum      ......  1 


The  other  21  were  into  the  medulla  and  cord.  It  will  be  seen  then 
that  hemorrhages  into  the  meninges  and  into  the  middle  lobe  of  the  brain 
are  of  most  frequent  occurrence.  It  will  be  well  to  state  that  large  por- 
tions of  both  hemispheres  may  be  destroyed  without  serious  symptoms ; 
but  when  we  approach  the  base  the  danger  is  increased,  and  if  the  third 
frontal  convolution  be  the  seat,  we  find  a  very  decided  and  serious  result, 
which  is  aphasia.  The  majority  of  hemorrhages  ar^  in  or  about  the  optic 
thalami  and  the  corpora  striata,  and  if  they  be  extensive  the  ventricles  will 
be  filled.  If  the  hemorrhage  be  great,  pressure  may  be  made  on  the  oppo- 
site side,  or  the  blood  may  find  its  way  into  other  localities.  In  the  ante- 
rior lobes  the  effusion  is  generally  circumscribed,  but  from  this  site  it  may 
find  escape  into  the  lateral  ventricles.  In  the  ganglia  and  important 
parts  at  the  base,  the  hemorrhage  is  generally  small,  but  is  of  the  most 
serious  character  because  of  the  importance  of  the  parts  it  destroys.  This 
is  the  case  in  the  corpora  striata.  In  the  pons  and  medulla  any  consid- 
erable extravasation  is  followed  by  death  or  serious  trouble.  The  shape 
of  the  cavity  is  variable,  but  in  the  gray  matter  it  is  circumscribed,  and 
in  the  white  it  is  irregular  and  elongated. 


100  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM 

Parrot1  reports  34  cases  of  cerebral  hemorrhage  in  new-born  children. 
In  these  the  clot  was  found  at  the  inferior  part  of  the  brain;  sometimes 
on  the  right  side,  but  more  generally  on  both  sides. 

Should  the  patient  survive  the  apoplectic  attack,  and  die  subsequently 
of  some  other  disease,  the  cerebral  clot  will  probably  prove  to  be  well 
organized,  hard,  and  separated  from  the  brain-tissue  in  the  vicinity  by  a 
sclerosed  mass.  The  immediate  changes  are  the  following:  At  the  end  of 
a  few  days  the  serum  is  absorbed,  leaving  the  solid  portion  as  a  gelatinous 
mass ;  finally  the  clot  contracts,  becomes  yellow,  and  assumes  the  appear- 
ance I  have  alluded  to.  It  is  rare  that  an  old  clot  is  completely  absorbed, 
but  it  is  found  encysted  and  firm,  and,  perhaps,  has  produced  some  soften- 
ing. It  is  not  uncommon  to  find  more  than  one  clot  in  a  patient  who 
has  had  several  hemorrhages.  There  may  be  a  cyst  filled  with  thick- 
ened blood,  which  is  indicative  of  an  effusion  of  recent  occurrence,  and 
there  may  be  others  of  smaller  size,  in  different  stages  of  resolution.  Small 
aneurismal  dilations  are  also  found,  while  local  patches  of  softening,  or 
cysts  filled  with  clear  serum,  are  not  rarely  present  at  the  same  time. 

A  common  form  of  hemorrhage  is  the  meningeal.  Goodhart2  has 
written  an  exhaustive  paper  upon  this  subject,  in  which  49  cases  are 
given,  proving  most  conclusively  its  connection  with  diseased  kidney  and 
hypertrophied  heart.  Of  these  49  cases,  30  were  due  to  renal  disease,  and 
six  had  uncomplicated  heart  trouble.  When  the  hemorrhage  takes  place 
above  the  arachnoid,  we  are  assured  by  Mr.  Prescott  Hewitt*  that  the 
blood  very  rarely  gravitates  to  the  base ;  but  when  the  hemorrhage  is  sub- 
arachnoid,  the  blood  may  find  its  way  below,  thus  making  the  condition  a 
most  serious  one.  After  death  a  peri-cortical  collection  of  blood  will  be 
found ;  which  is  extensive  over  the  base,  and  probably  produces  death  by 
pressure  upon  the  pons  and  medulla. 

Diagnosis.  —  Coincident  with  the  occurrence  of  the  hemorrhage, 
symptoms  will  be  presented  which  will  enable  us  to  localize  with  some 
degree  of  accuracy  the  position  of  the  clot,  its  extent,  and  character.  A 
lesion  in  or  about  the  corpus  striatum  will  be  followed  by  hemiplegia  of 
the  opposite  side.  The  temperature  being  higher  in  the  paralyzed  limbs 
than  in  the  others;  the  eyeballs  will  deviate  towards  the  side  of  the  lesion  ; 
and  the  tongue,  when  protruded,  will  point  to  the  hemiplegic  side.  The 
face  is  paralyzed  on  the  same  side  as  the  arm  and  leg.  A  lesion  in  or 
about  the  optic  thalanms  will  present  the  same  phenomena,  only  that  the 
temperature  is  higher  in  the  paralyzed  limb  than  in  the  preceding  form. 
A  lesion  in  one  cms  is  followed  by  very  much  the  same  symptoms.  If 
the  under  and  inner  part  be  affected,  we  find  cross  paralysis,  the  face 
being  paralyzed  on  the  side  of  the  lesion,  while  the  extremities  are  para- 
lyzed on  the  other  side  of  the  body.  Hemianaesthesia  is  quite  marked ;  and 
the  third  and  seventh  nerves  are  paralyzed,  so  that  ptosis  and  profound 

1   Arch,  dc  Tocologic,  1875. 

1  Guy's  Hosp.  Rep.,  vol.  xxi.  p.  181. 

*  Holmes's  System  of  Surgery,  1870. 


CEREBRAL    HEMORRHAGE.  101 

.- 

facial  paralysis  result.  A  lesion  in  one  lateral  half  of  the  pons  is  fol- 
lowed by  hemiplegia  of  the  opposite  side,  profound  coma,  deviation  of  the 
eyes  away  from  the  side  of  the  lesion,  facial  paralysis  on  the  side  of  the 
lesion,  lowered  temperature  in  the  non-paralyzed  limbs,  paralysis  of  the 
muscles  of  deglutition,  and  anaesthesia  or  hyperaesthesia  of  parts  supplied 
by  the  fifth  nerve.  A  lesion  of  the  upper  half  of  the  lateral  region  of  the 
pons  will  be  expressed  by  pretty  much  all  of  the  symptoms  which  follow 
the  last  mentioned  lesion,  except  that  the  facial  paralysis  will  be  on  the 
side  opposite  the  lesion.  A  feature  of  all  forms  of  lesions  in  the  pons  is 
the  very  decided  character  of  the  facial  paralysis ;  and  if  there  be  exten- 
sion of  the  lesion,  there  may  be  double  facial  paralysis,  with  hemiplegia  of 
the  body.  A  lesion  in  the  posterior  part  of  the  pons,  beside  the  symp- 
toms just  alluded  to,  will  produce  paralysis  of  the  fifth,  sixth,  and  seventh 
nerves  on  the  side  of  the  lesion ;  or,  according  to  Brown-Sequard,  it  may 
sometimes  produce  cross-paralysis.  A  lesion  in  the  centre  of  the  pons  is 
followed  by  double  paralysis,  deep  coma,  marked  contraction  of  pupils 
(while  in  the  other  forms  one  pupil  may  be  contracted  on  the  side  of  the 
lesion),  lowered  temperature  on  both  sides,  with  ultimate  rise  and  but 
slight  loss  of  sensation.  Louville1  reports  a  case  of  hemorrhage  into  the 
pons,  in  which  sugar  was  found  in  the  urine.  This  he  considers  to  be 
an  ever-present  symptom  of  disease  in  the  lower  part  of  the  pons,  but 
never  a  feature  of  disease  of  the  upper  part.  A  hemorrhage  in  the 
medulla  is  followed  by  paralysis  of  the  cranial  nerves  on  both  sides,  bi- 
lateral paralysis  of  the  body,  and,  generally,  rapid  death.  Extensive 
lesions  may  produce  a  combination  of  these  phenomena,  and  diagnosis 
may  sometimes  be  an  extremely  difficult  matter.  A  patient  under  treat- 
ment with  syphilitic  disease  of  the  brain,  presents  a  combination  of  symp- 
toms which  are  extremely  interesting  in  a  diagnostic  sense. 

Wm.  McG.,  aged  58  years,  when  about  21  years  of  age,  had  a  primary 
chancre  upon  the  dorsum  of  the  penis,  followed  some  months  afterwards 
by  secondary  symptoms.  After  a  few  years  all  traces  of  syphilitic  trouble 
seemed  to  have  disappeared,  as  he  enjoyed  extraordinary  good  health. 
He  has  led  for  the  last  twelve  or  fourteen  years  a  very  intemperate  life, 
and  has  regularly  "  gone  upon  sprees."  Twenty-six  months  ago,  after  ah 
attack  of  facial  neuralgia,  which  was  evidently  specific,  he  became  hemi- 
plegic  during  one  of  his  drinking  bouts,  but  does  not  remember  any  of  the 
circumstances  immediately  connected  with  the  apoplexy.  When  he  be- 
came sober  he  found  that  the  left  side  was  paralyzed,  but  the  loss  of 
power  could  not  have  been  very  great,  for  he  was  able  to  walk  in  a  few- 
days.  About  a  year  ago  the  right  side  of  the  face  became  anaesthetic,  and 
he  began  to  lose  the  sense  of  taste  on  the  left  side;  at  the  same  time  he 
found  it  difficult  to  arrange  the  food  for  mastication,  and  his  power  of 
articulation  became  embarrassed. 

PRESENT  CONDITION Eyes.  Pupils  of  the  same  size,  and  not  abnor- 
mal; respond  well  to  light ;  no  ptosis,  nor  disturbance  of  vision  ;  no  retinal 
change.  Face No  impairment  of  buccal  muscles,  nor  of  superficial 

1  Gazette  des  HGpitaux,  Feb.  8,  1873. 


102  DISEASES    OF    THE   CEREBRUM    AXD    CEREBELLl  M. 

• 

facial  muscles,  except  slight  contraction  of  those  of  right  side  when  he 
o(>ens  his  mouth.  When  this  is  done,  the  orifice  is  unsymmetrical.  Anos- 
mia marked,  taste  impaired  to  slight  degree.  Warm  substances  produce 
an  impression  on  sound  side  of  tongue,  but  not  on  the  other.  Left  side  of 
the  palate  paralyzed,  and  lower  than  the  other.  Left  side  of  tongue  atro- 
phied, presenting  the  appearance  depicted  in  Fig.  14  ;  and  when  protruded 
the  tip  points  to  the  right  side,  no  apparent  tactile  loss  of  sensation  as  de- 
termined by  the  sesthesiometer.  Saliva  is  secreted  in  large  quantities, 

Fig.  14. 


Multiple  Lesion  with  Tongue  Atrophy. 

and  constantly  drips  from  the  angles  of  the  mouth  when  he  talks.  Sensa- 
tion of  right  side  of  face  impaired ;  feels  points  only  when  separated  3  mm. 
on  other  side  1^;  some  difficulty  of  speech,  especially  with  the  letter  r, 
pronouncing  "righteous"  "eightehu;"  the  left  leg  he  drags  slightly  when 
lie  walks.  Six  months  ago  he  slept  upon  his  arm  when  drunk,  and  thereby 
added  to  his  other  troubles  a  decubitus  paralysis;  slight  loss  of  power  in 
both  arms. 

In  this  case  there  were  evidently  two  lesions — one  in  the  medulla,  and 
the  other  on  the  right  side  of  the  brain — one  hemorrhagic,  the  other  of 
slow  growth. 

AVe  are  to  diagnose  the  symptoms  of  cerebral  hemorrhage  in  its  different 
stages  from  those  of  the  following  diseases:  Actual  attack  from  urapmia, 
drunkenness,  opium  poisoning,  tumor,  epilepsy,  compression  or  concussion 
from  injury,  embolism,  and  thrombosis.  There  are  certain  general  ap- 
pearances which  symptomatize  the  ureemic  condition,  and  can  hardly  be 


CEREBRAL    HEMORRHAGE.  103 

mistaken ;  the  skin  is  waxy  and  cedematous,  the  eyelids  are  puffed,  and 
the  legs  and  feet  swollen;  but,  as  Bastian  suggests,  it  does  not  always  fol- 
low, when  we  find  these  appearances  in  an  individual  over  thirty  years 
of  age,  that  the  coma  is  always  purely  of  an  uraemic  character,  and  that 
there  may  not  be  a  complicating  hemorrhage.    The  urine,  when  drawn,  is 
found  to  contain  albumen,  but  this  symptom  by  itself  is  insufficient  to 
settle  the  question.     Unemic   coma  is  generally  of  gradual  appearance, 
though  Hughlings  Jackson  calls  attention  to  a  form  which  has  a  rapid  onset, 
with  convulsions ;  but,  on  the  whole,  such  sudden  appearance  is  more  suwes- 
tive  of  cerebral  hemorrhage.     It  is  nearly  always  preceded  by  prodromata 
for  several  days.     The  patient  is  stupid,  and  inclined  to  somnolence,  and  has 
headache.     Bourneville  has  ascertained  that  the  temperature  rapidly  sinks 
when  the  coma  begins,  to  a  point  very  much  lower  than  it  does  in  cere- 
bral hemorrhage,  and  continues  depressed  during-the  condition,  while  the 
converse  is  true  in  the  other  affection.     Convulsions  are  much  more  promi- 
nent and   constant  features  of  unemic   coma  than  they  are  of  cerebral 
hemorrhage ;  and,  beside,  there  is  no  paralysis.     Numerous  other  indica- 
tions will  serve  to  make  the  diagnosis  clear  in  this  respect.     The  coma  is 
not  deep,  and  it  is  possible  to  arouse  the  patient,  and  there  is  great  hyper- 
kinesis,  there  being  a  tendency  to  muscular  spasm  and  rigidity  which  is 
not  unilateral.     The  character  of  the  respiration  differs  from  that  of  cere- 
bral hemorrhage,  the  stertor  being  more  superficial.     From  drunkenness 
the  diagnosis  is  not  always  so  easily  made,  the  two  conditions  sometimes 
coexisting,  and  it  may  be  necessary  to  delay  until  the  effect  of  the  alcohol 
has  passed  away,  before  we  can  determine  our  patient's  true  condition. 
The  odor  of  liquor,  the  circumstances  under  which  he  was  found,  and  his 
imperfect  loss  of  consciousness,  are  sufficient  to  excite  suspicion.     If  he 
vomits,  we  may  chemically  test  the  substances  thrown  up,  or  we  may  ex- 
amine his  urine.     Anstie  gives  a  delicate  test  which  may  be  employed. 
If  even  only  one  drop  of  the  urine  of  the  patient  who  has  taken  a  toxic 
dose  of  alcohol  be  added  to  fifteen  minims  of  a  solution  of  one  part  of 
bichromate  of  potash  in  three  hundred  parts  of  strong  sulphuric  acid,  the 
mixture  will  turn  an  emerald  green.     With  a  larger  quantity  this  test  will 
be  much  more  certain.     The  articulation  of  an  intoxicated  person  when 
aroused  is  so  peculiar  and  so  interrupted  by  hiccough  that  there  need  be 
no  chance  for  mistake  in  this  respect.     Narcotic  poisoning  may  resemble 
somewhat  the  symptoms  indicating  cerebral  hemorrhage.     Like  alcoholic 
coma,  its  advent  is  gradual,  and  there  are  convulsions,  while  the  face  is 
dusky,  but  the  patient  may  be  generally  aroused.     Much  stress  has  been 
laid  upon  the  condition  of  the  pupil  in  opium  poisoning  as  a  diagnostic 
sign ;  but,  as  this  symptom  is  indicative  of  hemorrhage  in  the  pons,  it 
loses  some  of  its  value.     Epileptic  coma  can  hardly  be  mistaken  (should 
it  be  a  stage  of  the  actual  epileptic  attack)  for  that  of  cerebral  hemorrhage. 
In  the  former  there  is  a  history  of  convulsions  ;  the  stupor  lasts  but  for  an 
hour  or  two  at  the  most;  the  temperature  is  elevated;  and  there  is  some- 
times an  escape  of  bloody  froth  from  the  mouth.     The  previous  history  of 
the  patient  should  set  all  other  doubts  at  rest.     Compression  or  concussion 


104  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

from  head  injuries  may  be  mistaken  for  the  condition  under  consideration. 
In  the  former  there  may  be  a  subarachnoid  effusion,  which  may  give  rise 
to  many  of  the  symptoms.  The  latter  is  usually  of  short  duration,  so  far 
as  symptoms  are  concerned.  The  skin  is  pale,  the  pupils  dilated,  and 
vomiting  occurs  at  some  time  or  other.  It  is  always  of  decided  importance 
that  we  should  inquire  into  the  nature  and  receipt  of  the  injury;  for,  should 
it  follow  a  fall  while  the  patient  is  in  a  safe  position,  we  may  suspect  that 
he  has  had  a  seizure  of  some  kind,  the  injury  being  secondary  to  the 
attack. 

The  internal  cause  of  the  hemorrhage  is  always  important,  whether  it  be 
produced  by  an  abscess,  tumor,  or  other  intracranial  diseased  states ;  and 
these  tilings  are  to  be  taken  into  account.  The  antecedent  history  of  the 
patient,  the  presence  of  pain  of  a  localized  character,  subsequent  convulsion, 
loss  of  vision,  aural  disease,  and  kindred  conditions  should  all  be  ascertained. 
Serous  apoplexy,  as  it  has  been  called,  when  an  immense  effusion  of  serum 
takes  place  either  beneath  the  investing  membrane,  or  in  the  ventricles, 
or  throughout  the  brain  substance,  is  usually  of  gradual  origin,  and  de- 
pendent upon  the  collection  of  fluid  which  takes  the  place  of  atrophied 
brain  substance  or  attenuated  vessels. 

Prognosis According  to  all  observers  it  is  an  exceedingly  difficult 

matter  to  make  a  prognosis  with  any  certainty,  especially  an  early  one, 
and,  consequently,  it  is  of  the  utmost  importance  that  every  circum- 
stance of  the  case  should  be  taken  into  account  and  carefully  considered 
before  we  give  expression  to  any  opinion.  Certainty  of  prediction  is  made 
doubtful,  by  new  complications,  and  fresh  dangers  that  are  likely  to  arise. 
There  are  several  questions  that  are  to  be  answered,  and  the  first  of 
these  concerns  the  fatality  of  the  actual  attack.  The  character  of  the 
coma,  its  depth  and  duration,  the  appearance  of  convulsions,  abolition  of 
reflex  excitability,  stertor,  involuntary  passage  of  urine  and  feces  are  to 
be  regarded  as  indicative  of  an  early  fatal  termination.  If  this  condition 
be  connected  with  unequal  pupils,  and  double  hemiplegia,  the  prognosis  is, 
if  anything,  more  unfavorable.  Large  hemorrhages  into  the  ventricles,  cor- 
]Hmi  striata,  or  into  the  crura  or  pons  are  tjien  to  be  feared.  The  patient 
presenting  these  alarming  symptoms  dies  usually  in  a  very  short  time,  say 
in  from  a  few  hours  to  two  or  three  days,  and  there  may  be,  perhaps,  an 
aggravation  of  the  symptoms  towards  the  end  as  the  result  of  fresh  hemor- 
rhage. If  he  survives  the  attack,  what  are  the  chances  for  the  return  of 
mental  power  ?  or,  if  not  affected,  will  it  subsequently  become  impaired  ? 
This  depends  very  much  upon  the  occurrence  of  inflammatory  action  about 
the  clot,  or  whether  there  be  ursernic  trouble  or  softening.  We  may  augur 
well  for  his  chances  if  these  conditions  are  absent,  and  if  he  lives  for  eight 
or  ten  days  after  the  immediate  attack.  In  regard  to  the  speech  disturb- 
ances :  if  there  be  simple  ataxia,  there  is  no  reason  to  fear ;  if,  how- 
ever, any  marked  forgetfulness  of  words  or  genuine  aphasia  exists,  the 
prognosis  is  less  hopeful.  This  condition  of  affairs  often  exists  for 
years  without  the  slightest  improvement  taking  place.  At  first  the 
mind  is  confused  and  dull,  and,  unless  the  hemorrhage  is  the  result  of 


CEREBRAL    HEMORRHAGE.  105 

softening  or  other  degeneration,  there  is  but  little  doubt  that  he  will 
ultimately  regain  his  mental  activity.  It  is,  however,  well  to  qualify 
this  statement  by  saying  that  in  old  people  the  tendency  is  the  other  way. 
Congenital  apoplexies,  or  those  occurring  in  early  life,  are  apt  to  leave 
sequelae  of  the  most  deplorable  description,  such  as  imbecility  and  kin- 
dred conditions.  The  return  of  muscular  power  and  normal  sensation 
is  the  most  important  question  to  be  next  considered,  for  much  of  the 
patient's  future  comfort  depends  upon  the  recovery  of  his  lost  power. 
Should  the  limbs  remain  paralyzed,  or  secondary  neuritis  take  place,  the 
consequence  will  be  atrophy  and  contractures,  such  as  I  have  described. 
It  is,  however,  usual  for  recovery  to  begin  in  a  few  weeks,  and  in  even  a 
shorter  time  should  the  hemorrhage  be  unattended  by  loss  of  conscious- 
ness. The  limb  first  to  recover  is  the  lower  extremity.  He  is  able  after 
a  short  time  to  get  out  of  bed  and  "  hobble"  about,  or  he  may  retain  a 
certain  degree  of  power  from  the  first  should  the  hemorrhage  be  slight. 
He  is  subsequently  able  to  raise  his  hand  to  his  head,  and  ultimately 
recovers  entirely.  But  this  improvement  does  not  always  occur,  for 
during  a  cerebritis,  which  may  subsequently  take  place,  a  number  of  seri- 
ous muscular  distortions  of  a  permanent  character  may  ensue.  A  case 
illustrating  this  is  the  following : — 

J.  C.  D.,  aged  53  ;  born  in  Ireland  ;  carman.  Family  history,  mother 
died  of  old  age ;  father  died  of  renal  disease.  The  patient  in  early  life 
was  very  intemperate,  and  there  are  some  evidences  of  syphilitic  trouble, 
there  being  nodes,  bald  spots,  and  enlarged  glands ;  but  he  denies  any 
venereal  disease.  For  three  months  previous  to  the  attack  (it  occurred 
three  years  ago)  he  suffered  from  headache,  dizziness,  and  other  prodro- 
mal symptoms  ;  none  very  marked,  however.  He  went  to  bed  one  night 
feeling  perfectly  well,  and  awoke  with  "  cramps,"  which  affected  his  right 
leg  ;  he  called  his  wife,  and  attempted  to  get  out  of  bed,  when  he  found  he 
was  paralyzed.  There  was  no  speech  trouble  whatever.  He  was  placed 
in  bed,  and  remained  there  for  three  months,  during  which  time  he  had 
violent  headache  in  the  occipital  region. 

Present  Condition Hemiplegia  of  right  side,  sensibility  slightly  im- 
paired, and  no  atrophy  of  either  the  arm  or  leg.  When  he  stands  there  is 
slight  rigidity  of  the  inner  ham-strings.  The  toes  and  end  of  the  foot  are 
adducted ;  and  when  he  walks,  the  foot  is  raised  from  the  ground  about 
one  inch ;  the  knee  is  rigid,  and  there  is  motion  only  at  the  hip-joint.  The 
fingers  of  the  right  hand  are  in  a  condition  of  extreme  flexion,  and  cannot 
be  extended  by  ordinary  force  ;  but,  when  the  hand  is  placed  in  hot  water 
for  some  time,  the  rigidity  is  partially  overcome.  The  thumb  is  not  in- 
volved ;  but,  when  the  distal  phalanx  was  extended,  it  could  be  bent  back- 
wards some  distance,  and  remained  in  this  condition  until  it  was  restored 
by  me.  The  hand  is  slightly  flexed,  and  the  forearm  pronated  and  flexed 
on  the  arm,  and  the  arm  adducted  to  the  body.  No  lateral  movement  is 
possible.  There  was  an  early  history  of  neuritis,  which  came  on  a  short 
time  after  the  attack,  with  decided  pain  in  the  shoulder-joint,  during  which 
the  patient  applied  blisters  and  mustard  poultices.  The  dynamometer  in- 
dicates 20,  outer  circle,  with  the  right  hand,  and  80  with  the  left.  There 
is  no  visible  facial  paralysis,  but  the  tongue  points  slightly  to  the  right 


106  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

side.     The  surface  of  the  paralyzed  side  is  mottled  and  cold,  and  the  nails 
are  crenated  and  horny. 

The  facial  paralysis  is  sometimes  a  grave  and  permanent  condition,  and 
is  very  serious,  especially  if  there  be  ptosis.  Should  the  paralysis  involve 
the  muscles  of  the  pharynx,  the  tongue,  or  the  buccal  muscles,  the  prog- 
nosis is  very  bad,  and  these  symptoms  suggest  that  the  hemorrhage  luis 
invaded  the  posterior  basal  parts  of  the  brain,  and,  perhaps,  the  medulla. 
The  organs  of  special  sense  are  affected  to  a  variable  extent,  and  greatly 
modify  the  prognosis.  If  there  be  involvement  of  the  optic  disks,  retinal 
extravasations,  or  structural  changes  of  the  fundus,  a  grave  character  is 
given  to  the  disease  ;  while  such  symptoms  as  ptosis  and  diplopia,  which 
depend  upon  paralysis  of  the  third  and  sixth  nerve,  sometimes  disappear 
after  a  time,  though  such  disappearance  may  very  slowly  take  place.  The 
recurrence  of  apoplectic  attacks  is  not  uncommon,  and  if  there  be  any  spe- 
cial cachexia,  they  are  to  be  dreaded.  Syphilis  and  gout,  as  well  as  renal 
disease,  are  highly  conducive  to  a  return  of  the  trouble ;  or  advanced  age 
is  an  important  predisposing  cause  of  cerebral  hemorrhage.  When  we 
find  a  calcareous  state  of  the  arteries  with  cerebral  hemorrhage,  it  is  very 
probable  that  other  fluxions  will  follow.  I  remember  a  case  in  which  a 
succession  of  hemorrhages  occurred  in  the  person  of  a  middle-aged  lady, 
the  third  of  which  proved  fatal : — 

N.  G.  A.,  aged  57.  On  the  evening  of  February  3, 1873, 1  was  called  by 
Dr.  AVm.  H.  Bennett  to  see  the  patient,  whom  I  found  in  a  state  of  coma.  All 
of  the  characteristic  appearances  of  a  profuse  cerebral  effusion  were  mani- 
fested. The  apoplectic  seizure  had  taken  place  the  day  before,  and  she  had 
continued  in  a  comatose  state  until  I  saw  her  with  Dr.  Bennett.  Her  surface 
was  cool,  her  breathing  slow  and  stertorous,  her  pupils  dilated,  and  corneae 
insensitive  to  the  touch  ;  while  reflex  excitability  was  entirely  abolished, 
so  that  tickling  of  the  soles  was  followed  by  no  withdrawal  of  either  limb. 
In  this  state  she  remained  until  the  8th  of  the  month,  during  which  time, 
and  in  fact  until  the  time  of  her  death,  in  November  of  the  same  year,  it 
was  necessary  to  draw  her  water  nearly  every  day.  At  the  end  of  the 
fifth  day  there  was  a  slight  return  of  consciousness,  but  entire  inability  to 
speak,  the  patient  making  a  peculiar  short  sound  when  she  wished  to  com- 
municate with  those  about  her.  There  was  complete  paralysis  of  the  right 
side,  but  a  faradic  current  readily  produced  muscular  contractions.  From 
this  period  until  September  13th,  there  was  steady  improvement,  and  the 
family,  as  well  as  ourselves,  were  very  hopeful.  She  recovered  consider- 
able power  over  the  leg  and  arm,  but  was  unable  to  get  out  of  bed,  although 
she  was  lifted  from  it  and  placed  in  an  easy  chair,  where  she  remained 
contented  for  several  hours  of  the  day.  She  was  now  able  to  utter  two  or 
three  words,  and  seemed  to  take  a  lively  interest  in  all  that  went  on  about 
her.  On  the  13th  of  September,  while  lying  in  bed,  she  suddenly  became 
comatose,  and  presented  all  the  symptoms  of  a  fresh  hemorrhage.  Her 
temperature,  which  had  before  ranged  between  98°  and  101°,  now  sank 
to  90°;  and  her  condition  was  so  critical  that  I  remained  with  her  during 
the  night  of  the  14th,  when  she  slightly  recovered,  regaining  her  con- 
sciousness on  the  17th  ;  but  there  was  complete  loss  of  power.  The  tem- 
perature now  rose  to  104°,  and  she  was  restless  and  irritable.  Her  power 


CEREBRAL    HEMORRHAGE.  107 

of  expression   had  entirely  disappeared,  and  she  remained  in  this  state 
until  the  19th  of  November,  when  she  died  in  her  last  apoplectic  attack. 

This  patient,  before  her  last  illness,  had  suffered  for  some  time  from 
albuminuria,  but  her  symptoms  had  been  almost  entirely  relieved  when 
her  first  cerebral  hemorrhage  took  place.  She  was  of  spare  build,  her 
radial  arteries  were  rigid,  and  the  arcus  senilis  was  visible  to  a  limited 
extent. 

This  tendency  to  cerebral  hemorrhage  is  sometimes  seen  in  gouty  sub- 
jects. A  patient  recently  sent  to  me  by  Dr.  William  Lockwood,  of  Nor- 
walk,  Conn.,  had  suffered  for  years  from  gouty  trouble.  Besides  the  pain 
her  joints  presented  gouty  swellings,  with  chalky  concretions.  Within 
the  past  five  years  she  has  suffered  from  slight  hemiplegia  of  both  sides ; 
on  the  right  most  severely.  In  this  case  it  is  probable  that  the  rupture  of 
a  large  vessel  will  some  day  carry  her  off. 

Treatment — Our  treatment  must  be,  first,  preventive,  second,  for 
the  attack,  and  third,  for  the  amelioration  of  the  resulting  condition.  If 
we  have  to  deal  with  cachexias  of  different  kinds,  appropriate  treatment  is 
indicated.  Should  there  be  gouty  trouble,  albuminuria,  or  syphilis,  these 
are  to  be  met  with  alkalies  (FF.  45,  46),  diuretics  (FF.  18, 19),  and  specific 
remedies  (F.  20)  such  as  mercury  and  the  iodides.  If  there  be  depraved 
general  health,  weak  heart  action,  and  general  debility,  we  are  to  support 
our  patient  by  quinine,  stimulants,  and  nourishing  food.  Combinations 
of  digitalis  and  iron  (F.  21)  are  especially  useful  when  there  is  low  ar- 
terial tension,  and  rapid  heart  action.  In  speaking  of  cerebral  congestion 
I  alluded  to  the  conditions  which  might  favor  an  excessive  flow  of  blood 
to  the  head,  and  advocated  special  forms  of  treatment.  It  is  not  necessary 
to  repeat  these  indications,  but  I  will  simply  refer  to  the  value  of  the  bro- 
mides given  in  doses  of  from  20  to  30  grains  three  times  a  day  if  there  be 
any  tendency  to  head  fulness,  while  ergot  administered  in  half-drachm  doses 
two  or  three  times  during  the  24  hours,  and  the  abstraction  of  blood  from 
behind  the  ears,  may  be  resorted  to,  should  there  be  a  suspicion  of  imme- 
diate danger.  The  patient  is  to  be  kept  perfectly  quiet  in  a  cool  room, 
cold  applications  are  to  be  made  to  the  head,  and  his  bowels  should  be 
emptied  by  some  such  cathartics  as  the  compound  jalap  powder,  senna,  or 
Rochelle  salts.  Should  we  recognize  the  appearance  of  any  prodromal 
symptoms,  we  must  immediately  inform  the  patient  of  the  dangerous  pos- 
sibility, and  enjoin  upon  him  the  necessity  of  regulating  his  mode  of  life, 
of  breaking  off  bad  habits,  and  using  every  means  in  his  power  to  improve 
cutaneous  circulation.  The  flesh-brush,  cold,  and  sometimes  Turkish 
baths,  moderate  out-door  exercise,  and  other  agents  which  stimulate  the 
surface  capillaries  and  relieve  internal  congestion,  should  be  as  soon  as 
possible  resorted  to.  The  patient's  diet  should  be  farinaceous,  and  the 
us,e  of  either  strong  drink  or  condiments  is  to  be  at  once  discontinued.  He 
is  to  sleep  in  a  cool  room,  and  on  no  account  wear  tight  neck  gear.  The 
feet  are  to  be  kept  warm,  and  thick  woollen  stockings  should  be  recom- 
mended. Violent  exertion,  especially  forms  requiring  any  fixation  of  the 


108  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

abdominal  muscles  or  straining,  are  also  to  be  carefully  guarded  against. 
Should  we  be  called  to  find  the  patient  in  the  actual  apoplectic  state, 
another  line  of  treatment  must  be  followed  out.  If  in  this  condition  he  is 
found  lying  in  a  comatose  state  upon  the  floor,  he  is  to  be  lifted  gently, 
carried  to  a  bed,  and  well  propped  up  by  pillows  so  that  the  head  is 
elevated.  The  room  should  be  kept  cool  and  well  ventilated,  and  cold 
applications  are  to  be  applied  to  his  head,  while  his  feet  may  be  kept 
warm  by  contact  with  bottles  filled  with  hot  water.  The  room  is  to  be 
darkened,  and  his  collar  and  shirt  collar  band  should  be  cut  or  ripped  off, 
so  that  the  flow  of  blood  to  and  from  the  head  shall  be  unembarrassed.  It 
is  essential  to  keep  him  perfectly  quiet ;  so  loud  talking  is  to  be  forbidden, 
and  officious  friends  kept  away.  In  times  gone  by,  it  was  customary  always 
to  bleed  at  this  stage.  I  think  experience  has  clearly  proven  how  dan- 
gerous is  such  practice,  for  hemorrhage  in  the  brain  is  very  apt  to  be  started 
afresh  by  any  such  measure.  If,  however,  the  pulse  be  full,  strong,  and 
bounding,  the  patient's  face  flushed,  and  his  condition  one  of  plethora,  the 
abstraction  of  a  few  ounces  of  blood  from  behind  the  ears,  with  cold  douches 
to  the  head  and  mustard  plasters  to  the  calves,  will  do  much  good.  This 
condition  may  be  so  patent  to  the  observer  that,  perhaps,  in  rare  instances 
and  after  careful  deliberation,  he  may  decide  to  abstract  ten  or  twelve 
ounces  from  the  arm.  If  we  hear  that  he  has  been  constipated  for  several 
days,  a  drop  or  two  of  croton  oil  or  half  a  grain  of  elaterium  (F.  22)  may 
be  given  in  a  wafer,  or  applied  to  the  tongue  if  he  is  unable  to  swallow  ;  it 
is  advisable  to  give  the  first  remedy,  however,  if  the  patient  is  profoundly 
comatose.  Should  there  be  much  cardiac  excitement,  no  better  medicines 
can  be  recommended  than  tincture  of  veratrum  viride  (F.  36),  or  tincture 
of  aconite  ;  the  former  in  doses  of  from  6  to  8  minims  till  the  pulse  force 
is  decreased,  and  the  latter  in  rather  large  doses,  say  from  4  to  6  minims 
at  a  time,  and  after  an  interval  of  four  hours,  another  dose,  if  the  pulse 
has  not  decreased  in  volume  or  frequency.  The  medical  attendant  should 
not  forget  to  draw  the  patient's  urine  frequently.  I  have  known  a  neglect 
of  this  precaution  to  be  followed  by  pain  and  distress  which  the  patient  in 
his  helplessness  is  unable  to  express ;  and  I  cannot  impress  too  strongly 
upon  the  student  the  necessity  of  remembering  this  simple  procedure. 
When  consciousness  returns  we  may  continue  the  aconite  if  it  is  indicated, 
and  perhaps  combine  it  with  small  doses  (say  10  grains)  of  the  bromide  of 
sodium  (F.  1)  every  two  hours.  Active  medication  of  any  kind,  how- 
ever, is  injudicious  in  the  extreme ;  so  it  will  not  do  to  give  large  doses. 
Should  there  be  a  condition  of  prostration,  a  tablespoonful  or  two  of  rnilk 
punch  may  be  given  every  few  hours.  The  subsequent  management  of 
the  case  is  sufficiently  simple  ;  continued  quiet,  a  moderate  quantity  of 
food  easy  of  digestion,  and  attention  to  the  functions  of  the  body  are  the 
three  indications.  He  should  not  be  allowed  to  get  up  to  defecate,  but 
the  bed-pan  may  be  placed  beneath  him.  It  may  be  found  necessary  to 
give  an  enema,  which  is  better  than  the  administration  of  purgatives  by 
the  mouth,  and  in  this  case  the  patient  should  not  be  allowed  out  of 
bed,  even  though  he  may  seem  bright  and  sufficiently  strong.  Cleanliness 


CEREBRAL    HEMORRHAGE.  109 

should  be  insisted  upon,  and  generally  necessitates  the  faithful  care  of  a 
responsible  nurse;  for,  if  the  patient  is  not  carefully  washed,  the  irritation 
produced  by  alkaline  urine  and  his  loose  evacuations  may  favor  the  devel- 
opment of  bedsores.  As  a  precautionary  measure,  the  buttocks  should  be 
rubbed  with  salt  and  whiskey,  or,  what  is  still  better,  tannin  and  alcohol. 
Bedsores  may  occasionally  form,  and  sometimes  are  unnoticed  by  the 
physician  if  he  is  not  on  the  alert,  until  his  nose  or  the  nurse  remind  him 
of  their  existence,  the  patient  either  being  unconscious  of  such  trouble,  or 
unable  to  inform  the  physician  even  if  he  is  aware  of  their  presence.  The 
patient  should  be  immediately  put  on  a  water  bed,  and  the  slough  re- 
moved by  poultices  of  flax-seed  and  charcoal  which  may  be  sprinkled  with 
iodoform.  At  the  end  of  the  8th  or  9th  day,  should  the  tendency  be 
to  recovery,  and  the  temperature  normal,  we  are  left  with  an  ordinary 
case  of  hemiplegia.  What  is  to  be  done  next?  If  the  attack  has  been 
a  serious  one  and  signalized  by  marked  loss  of  consciousness,  and  if 
the  secondary  rise  of  temperature  be  high,  it  is  not  best  to  begin  elec- 
trical treatment  for  fully  a  month  or  longer.  If  the  muscles  respond 
too  quickly  to  electric  stimulus,  we  are  not  to  use  this  agent,  but  to  wait 
for  some  days  or  weeks,  when  we  may  cautiously  employ  the  faradic  cur- 
rent to  the  muscles  of  the  affected  side.  Large  sponge-covered  electrodes 
moistened  in  a  salty  solution  should  be  employed,  so  that  all  the  muscles 
may  be  subjected  to  the  electric  stimulus  in  turn.  Electrization  may  be 
direct  or  indirect,  the  muscles  being  made  to  contract  either  when  both 
sponges  are  applied  to  their  bellies,  or  when  one  is  placed  in  contact  with 
the  muscle  and  the  other  is  applied  over  the  motor  nerve  by  which  it  is 
supplied.  In  certain  cases  faradization  fails  to  do  any  good  whatever,  and 
this  is  especially  the  case  when  there  is  delay  in  the  absorption  of  the 
clot  or  any  cerebritis.  Two  cases  illustrating  the  possible  advantages  of 
this  form  of  treatment  are  the  following  : — 

Right  Hemiplegia;  Cure O.  S.,  aged  52,  butler,  came  under  my 

charge  October  2d,  1872.  He  had  been  deprived  of  consciousness  and 
power  of  motion  a  year  before  by  a  cerebral  hemorrhage,  and,  after 
resuming  the  duties  of  his  avocation  some  months  afterwards,  continued 
well  till  three  months  ago,  when  a  second  attack  prostrated  him ;  but, 
through  the  good  treatment  he  received  at  Bellevue  Hospital,  he  partially 
recovered  the  power  of  locomotion.  When  he  came  to  me  for  treatment 
there  was  complete  hemiplegia  of  the  left  side.  There  was  no  peculiarity 
in  his  gait,  beyond  a  very  slight  dragging.  The  arm  was  slightly  atro- 
phied, and  the  amount  of  power  exerted  by  a  forcible  grasp  of  the  dynamo- 
meter was  indicated  by  15°  of  the  lesser  circle.  He  could  not  button  his 
clothes,  nor  lift  his  arm  above  his  head.  There  was  no  difficulty  in  speech, 
except  it  might  be  embarrassment  in  speaking  the  words  containing  the 
letters  "  b"  and  "p,"  when  the  labial  muscles  were  required. 

Electric  irritability  in  the  arm  was  slightly  exaggerated.  After  giving 
him  a  simple  prescription  for  his  constipation,  I  dismissed  him. 

In  three  weeks  afterward  he  returned  in  very  much  the  same  condition. 
I  then  systematically  applied  the  galvanic  current  to  the  head,  and  the 
faradic  to  the  limbs.  The  improvement  was  marked  and  immediate. 


110  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

The  muscles  lost  their  atrophic  state,  and  became  firmer  and  larger.  The 
patient  was  able  to  perform  many  actions  with  his  hands  not  possible  be- 
fore this  treatment.  Faradization  to  the  lips  and  cheek  has  effectually 
overcome  the  facial  paralysis,  and  he  now  speaks  distinctly. 

Cerebral  Softening;  Right  Hemiplegia;  Slight  Improvement.  —  H. 
Walker,  aged  02,  Germany,  canal-boat  captain,  presented  himself  for  treat- 
ment in  December  with  a  well-marked  right  hemiplegia.  He  had  been 
injured  some  time  before  while  on  the  deck  of  his  canal-boat,  and  then  hit 
upon  the  head.  He  was  senseless  for  some  days,  but  recovered,  with  se- 
vere cerebral  disturbance,  which,  from  his  wife's  statement,  must  have 
been  inflammation  of  the  cerebral  substance. 

He  left  his  bed  after  some  weeks,  with  persistent  pain  in  the  head, 
aphasia,  trembling,  and  a  heavy  feeling  of  the  lower  limbs.  His  memory 
and  other  mental  faculties  became  obscured,  and  there  was  an  uneasy 
expression  of  the  eyes.  About  a  year  after  the  receipt  of  his  original  in- 
jury, while  working  one  day  in  the  sun,  he  had  an  apoplectic  fit. 

After  remaining  in  bed  some  time,  muscular  power  and  cutaneous  sen- 
sibility slowly  came  back.  He  was  able  to  walk  with  difficulty;  his  speech 
was  indistinct ;  the  muscles  of  both  the  leg  and  arm  were  greatly  atrophied ; 
and  I  determined  to  use  faradism. 

The  constant  use  of  the  very  mild  current  for  several  weeks  brought 
back,  to  some  degree,  the  original  contour  of  the  paralyzed  muscles.  He 
was  able  to  progress  with  a  cane,  but  his  speech  remained  imperfect. 
During  the  treatment  he  had  repeated  premonitory  signs  of  a  new  attack. 
Faradism  was  resorted  to  to  prevent  atrophy,  but  its  good  effects  were 
only  temporary,  as  there  is  still  softening. 

In  connection  with  this  treatment  we  may  give  at  the  same  time  either 
iodide  of  potassium,  strychnine,  or  ergot. 

Iodide  of  Potassium — Should  there  be  a  syphilitic  history,  I  think  we 
may  begin  at  once  with  this  remedy.  If  there  be  no  such  dyscrasia,  I  do 
not  approve  of  the  remedy  at  any  time.  It  is  administered  very  often 
with  the  idea  of  producing  absorption  of  the  clot,  and  is  recommended  by 
many  writers.  My  limited  experience  has  convinced  me  that  its  virtues 
have  been  very  much  overestimated.  I  have  found  that  in  many  cases 
the  patient's  tendency  to  recovery  was  hastened  more  by  rest,  good  food, 
and  fresh  air,  than  by  any  other  form  of  medication.  It  is  perhaps  of 
value  in  old  cases. 

Phosphorus — Either  in  its  pure  state  (FF.  24,  25,  26),  or  in  combina- 
tion with  zinc,  it  is  of  great  benefit  in  cases  of  long  standing,  especially  if 
there  be  debility  and  tardy  restoration  of  power  in  the  paralyzed  limb. 
The  phosphide  of  zinc  (F.  27)  in  doses  of  one-third  of  a  grain,  or  dilute 
phosphoric  acid  in  half-teaspoonful  doses,  are  perhaps  better  borne  than 
pure  phosphorus. 

Strychnine  is  entitled  to  more  consideration.  If  used  at  the  proper 
time,  it  is  more  powerful  to  do  good  than  any  other  remedy  I  know  of, 
ix-rhaps  excepting  electricity.  When  the  exaggerated  electro-muscular 
irritability  subsides,  we  may  give  it  in  doses  of  ^  of  a  grain  three 
times  a  day  (F.  29),  but  before  this  time  its  use  is  attended  with 
danjrer. 


CEREBRAL    HEMORRHAGE.  Ill 

Vance1  has  recommended  hypodermic  injection  of  strychnine,  but  I 
always  hesitate  when  injecting  an  irritating  substance  into  the  belly  of  a 
paralyzed  muscle,  for  I  have  repeatedly  seen  abscesses  follow  the  use  of 
even  a  neutral  solution  properly  injected.  Impaired  muscular  vitality  and 
tardy  reparative  nutrition  do  not  favor  its  use.  However,  Bartholow, 
Eulenberg,  and  Echeverria  recommend  its  employment,  and  have  had 
good  results.  Perhaps  in  paralysis  of  central  origin  the  trouble  to  which 
I  have  alluded  is  not  so  much  to  be  feared  as  when  the  affection  is  peri- 
pheral. Each  muscle  is  to  be  subjected  to  injection  (F.  30),  one  being  so 
treated  each  day.  Instead  of  the  plan  recommended  by  these  authorities, 
viz.,  injections  into  the  substance  of  the  muscle,  I  prefer  local  subcutaneous 
introduction  of  the  solution  by  the  hypodermic  syringe.  In  addition  to 
electric  treatment,  it  is  well  to  resort  to  massage  and  passive  movement  of 
the  contracted  members.  The  patient  may  be  directed  to  do  this  himself, 
and  he  should  be  told  to  rub  the  paralyzed  limb  several  times  daily  for  at 
least  fifteen  minutes  at  a  time.  Dr.  G.  M.  Beard  has  recommended  heat 
in  the  treatment  of  paralysis,  and  his  plan  is  to  place  the  affected  limb  in 
a  heated  earthen  drain  pipe,  well  lined  with  flannel.  I  can  quite  agree 
with  him,  but  have  found  that  alternate  heat  and  cold  applied  to  the  sur- 
face produce  more  rapid  improvement  in  nutrition  of  parts  which  have  lost 
their  power.  I  originally  recommended  the  instrument  depicted  in  Fig  15, 
which  will  be  found  a  cleanly  and  convenient  apparatus.  One  receptacle 
is  filled  with  hot  water,  the  other  with  cold.  If  the  contracted  limbs 

Fig.  15. 


Instrument  for  applying  Heat  and  Cold. 

where  lately  rigidity  had  taken  place  are  allowed  to  remain  daily  for 
fifteen  minutes  or  half  an  hour  in  quite  hot  water,  much  benefit  will 
follow;  or,  should  there  be  neuritis,  we  may  use  blisters,  or  the  actual 
cautery  along  the  course  of  the  nerve  trunk.  It  is  of  the  utmost  impor- 
tance that  everything  should  be  done  to  improve  the  patient's  hygienic 
surroundings,  diet,  and  habits.  He  should  not  remain  in-doors,  but  stay 
in  the  open  air  as  much  as  possible.  Food  of  a  nutritious  but  not  of  a 
fatty  character,  moderate  stimulation  if  needed,  and  a  course  of  tonics, 
may  constitute  our  form  of  treatment  during  this  late  stage  of  the  dis- 
ease. 

1  Journal  of  Psychological  Medicine,  April,  1870. 


112  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 


CEREBELLAR  HEMORRHAGE. 

Very  little  has  been  written  in  regard  to  effusions  of  blood  into  the 
cerebellum,  and  the  diagnosis  of  such  a  condition  is  attended  by  many 
difficulties.  An  excellent  thesis  on  the  above  subject,  by  Dr.  Carion,1 
contains  the  following  conclusions  in  regard  to  diagnosis  of  this  disease : — 
"  The  predominating  symptom  of  cerebellar  hemorrhage  is  general 
enfeeblement  of  the  muscular  system.  Hemiplegia  is  relatively  rare  ; 
when  it  exists  it  is  sometimes  crossed,  sometimes  direct.  Facial  paralysis 
is  exceptional ;  it  involves  the  orbicular  muscle  of  the  eyes,  and  occurs 
on  the  side  of  the  lesion,  and  it  has  for  its  cause  the  compression  of  the 
seventh  pair  at  its  point  of  emergence.  The  tongue  presents  a  certain 
degree  of  asthenia,  shown  by  a  weakness  in  its  movements,  without  de- 
viation. Strabismus,  like  the  facial  paralysis,  is  not  observed  as  a  symp- 
tom of  cerebellar  origin ;  it  may  occur  from  compression  of  some  one  of 
the  motor  nerves  of  the  eye.  The  conjugated  deviation  of  the  eyes  has 
been  observed ;  it  always  occurs  towards  the  uninjured  side  as  for  other 
parts  of  the  encephalic  isthmus.  The  pupils  are  sometimes  dilated — more 
frequently  contracted;  they  sometimes  react  under  the  influence  of  light, 
and  are  insensible.  General  sensibility  is  unaltered  even  when  hemipleiria 
exists ;  we  barely  observe  a  slight  anaesthesia  in  a  few  rare  cases ;  hyperses- 
thesia  is  still  less  frequent.  Troubles  of  special  sensibility,  principally  of 
sight,  have  been  observed,  but  they  are  very  rare  exceptions.  The  in- 
telligence is  generally  preserved  in  all  its  integrity.  Vomiting  is  scarcely 
ever  absent,  and  it  can  rightly  be  deemed  one  of  the  more  characteristic 
symptoms  of  cerebellar  hemorrhage." 


Abstracted  in  Chicago  Journal  of  N.  Disease,  vol.  ii.  p.  621. 


CEREBRAL    ANAEMIA.  H3 


CHAPTEK    III. 

DISEASES  OF  THE  CEREBRUM  AND  CEREBELLUM  (CONTINUED). 
CEREBRAL  ANJEMIA. 

Synonyms — Syncope,  Anemie  Cerebrale,  Hydrocephaloid. 

Definition — A  morbid  state  characterized  by  an  insufficient  cerebral 
blood-supply,  and  expressed  by  impairment  of  consciousness,  pallor,  and 
much  muscular  enfeeblement.  This  disease  is  capable  of  quite  as  great 
modification  as  cerebral  hyperaemia,  as  it  may  be  what  only  appears  to  be 
a  continued  physiological  condition,  or  a  grave  pathological  state.  Cere- 
bral anremia  may  occur  :  1,  in  an  acute  form  (syncope)  ;  2,  in  a  chronic  form  ; 
3,  in  an  infantile  form  (the  hydrocephaloid  of  Marshall  Plall)  ;  and,  4,  it  is 
localized  or  partial,  as  a  result  of  vascular  obstruction.  The  acute  form, 
which  may  be  only  a  simple  fainting  attack,  or  the  result  of  shock  follow- 
ing severe  hemorrhage,  is  the  most  familiar  variety.  It  is  hardly  neces- 
ssary  to  describe  the  alarming  and  familiar  condition  that  we  occasionally 
meet  with  after  post-partum  hemorrhage,  or  protracted  decubitus,  when  the 
patient  assumes  the  erect  posture.  The  chronic  variety  is  much  less  serious 
in  its  earlier  stages,  though,  when  continued,  it  is  often  the  forerunner  of 
certain  forms  of  insanity.  It  is  symptomatized  by  lowered  function  of  the 
cerebral  ganglia,  depraved  nervous  tone,  and  general  intellectual  apathy  ; 
for,  as  normal  circulation  is  necessary  for  the  support  of  healthy  brain 
action,  and  as  we  find  that  rapidity  of  thought  and  emotional  activity  are 
proportionate  to  the  increase  in  the  cerebral  blood-supply,  so  must  insuffi- 
cient circulation  bring  with  it  an  impaired  state  of  intellectual  functional 
activity.  This  loss  of  healthy  action  may  be  expressed  by  drowsiness, 
obscured  intelligence,  or  by  irritability  and  restlessness. 

The  infantile  form  generally  follows  some  of  the  continued  fevers  of 
early  life,  and  is  a  disease  of  childhood.  Occurring  during  the  stage  of 
convalescence  of  the  acute  form,  it  is  symptomatized  by  semi-conscious- 
ness, diarrhoea,  great  exhaustion,  insensitive  pupils,  pallor,  sighing  respi- 
ration, and  other  symptoms. 

The  last  variety,  local  or  partial  cerebral  anaemia,  is  that  which  is 
usually  productive  of  right  hemiplegia,  and  is  due,  in  the  majority  of 
cases,  to  thrombosis  or  embolism,  and  often  has  a  grave  termination. 

It  is  hardly  necessary  to  allude  to  Acute  Cerebral  Anaemia,  for  it  comes 
within  the  province  of  the  surgeon  rather  than  within  that  of  the  neurologist. 
Following  some  grave  accident  when  there  is  sudden  and  excessive  loss 
of  blood,  we  will  h'nd  a  corresponding  loss  of  consciousness,  and  muscular 
power,  sighing,  and  slow  respiration,  generally  vomiting,  and  involuntary 
discharge  of  feces  and  urine. 


114  DISEASES   OF    THE    CEREBRUM    AND    CEREBELLUM. 

The  condition  is  not  a  lasting  one,  and  provided  the  hemorrhage  has 
not  been  too  excessive,  or  the  shock  too  great,  there  may  be  a  retrograde 
disappearance  of  the  symptoms,  and  ultimate  recovery. 

Symptoms A.  IN  CHRONIC  CEREBRAL  ANEMIA — Subjective — 

Our  patient  complains  of  muscular  debility,  backache,  loss  of  appetite, 
and  somnolence,  with  great  despondency,  increasing  loss  of  memory, 
marked  headache,  a  regularly  distributed  cutaneous  anaesthesia,  some- 
times vomiting,  hallucinations  of  sight  and  hearing,  palpitation,  indiges- 
tion, and  constipation.  Objective — Pallor  of  the  skin,  particularly  of  the 
face,  which  is  of  a  dirty  white  color,  while  the  sclerotics  are  milky  blue, 
and  the  pupils  widely  dilated.  The  patient's  expression  is  one  of  anxiety 
and  depression,  and  if  the  condition  be  advanced  and  of  long  standing, 
he  will  spend  hours  with  downcast  eyes  and  a  painful  hopelessness,  and 
hebetude  stamped  upon  every  feature.  Coldness  of  the  hands,  heart - 
murmurs,  and  a  weak,  small  pulse,  are  strong  evidences  of  defective 
circulation  of  this  description.  The  sphygmograph  gives  an  almost 
straight  tracing,  the  pulse-beats  being  weak  and  small.  I  have  been 
told  very  often  by  these  patients  that  it  was  with  very  great  difficulty 
that  they  could  refrain  from  falling  asleep  in  public  places,  and  one 
lady  was  in  the  habit  of  becoming  so  drowsy  in  the  street  car  on  her 
way  to  my  office  that  she  very  often  unconsciously  passed  the  street. 
Women  who  suffer  in  this  way  are  subject  to  fainting  attacks,  which 
occur  most  often  during  the  menstrual  period.  Among  the  most  aggra- 
vating symptoms  are  hallucinations  of  hearing  ;  noises — such  as  ringing  of 
bells — are  heard;  and  they  occasionally  have  visual  hallucinations  in  con- 
nection therewith.  Delusions  are  very  unusual.  Insomnia  is  some- 
times a  distressing  symptom,  though  during  the  day,  as  I  have  before  said, 
the  patient  may  have  great  difficulty  in  keeping  awake.  It  is  not  un- 
common for  him  to  complain  of  a  sensation  as  of  falling  through  the  bed  ; 
and  one  of  the  prominent  elements  of  his  sleeplessness  is  the  continuous 
roaring  in  his  ears,  which  is  sometimes  compared  to  the  sounds  heard 
when  a  shell  or  other  hollow  body  is  placed  over  the  ear.  If  the 
condition  has  gone  on  to  the  state  where  mental  impairment  has  begun, 
we  will  generally  find  that  there  is  venous  stasis,  and  that  the  back  of 
the  hands  is  of  a  livid  color,  while  pressure  leaves  a  white  mark  which 
slowly  disappears.  The  lips  are  pale,  thick,  and  puffed,  and  the  line 
between  the  mucous  membrane  and  skin  is  less  sharply  defined  than  in 
the  normal  state.  The  urine  is  passed  in  large  quantities,  is  colorless 
and  limpid,  and  of  a  low  specific  gravity.  The  heart-sounds  are  weak, 
and  it  is  not  uncommon  to  find  an  aortic  bellows  murmur.  There  may  be 
amaurosis,  and  other  defects  of  vision.  Digestive  derangements  are  quite 
common,  and  vomiting,  which  is  cerebral,  is  in  some  cases  frequent  and 
obstinate.  The  individuals  presenting  these  symptoms  are  poorly 
nourished.  There  may  be  oedema  of  the  legs  and  ankles,  and  sometimes 
albuminuria.  Feebleness  and  muscular  want  of  power,  of  a  light  grade, 


CEREBRAL    ANJEMIA  ]  15 

are  often  expressed ;  and  the  comfort  of  a  sofa  or  easy  chair  is  sought  by 
the  patient,  who  seems  disinclined  to  take  any  exertion  whatever. 

B.  IN  INFANTILE  CEREBRAL  AX.EMIA — Marshall  Hall  has  called  atten- 
tion to  a  most  interesting  form  of  ansemia,  to  which  I  have  casually  referred, 
and  to  which  he  has  given  the  name  "  Hydrocephaloid."  The  disease 
depends  principally  upon  exudation,  and  has  its  origin  in  early  infancy. 
A  case  is  related  by  Hall : — 

"  The  patient,  a  boy,  aged  four,  became  comatose  and  perfectly  blind 
and  deaf.  The  finger  might  approach  the  half-closed  eye  without  induc- 
ing any  movement,  but  the  moment  it  touched  the  eyelash,  the  eyelids 
would  close.  A  spoon  applied  to  the  lips  excited  their  action,  and  the 
food  it  contained  was  carried  into  the  pharynx  and  swallowed  ;  the  respi- 
ration was  frequently  suspended ;  a  sigh,  and  frequent  respiration  fol- 
lowed. The  cerebral  functions  had  ceased  ;  the  true  spinal  functions  were 
made."1 

Marshall  Hall  lays  down  certain  rules  from  which  I  may  extract  the  fol- 
lowing. We  should  especially  be  upon  our  guard  not  to  mistake  the  stupor 
or  coma  into  which  the  state  of  irritability  is  apt  to  subside,  for  natural 
sleep,  and  for  an  indication  of  returning  health.  "  The  pallor  and  cold- 
ness of  the  cheeks,  the  half-closed  eyelid,  and  the  irregular  breathing,  will 
sufficiently  distinguish  the  two  cases."  He  divides  the  affection  into  two 
stages,  the  first  of  which  is  one  of  irritability,  the  second,  of  coma.  In  the 
former  there  is  some  attempt  at  reaction,  and  in  both  stages  there  is 
some  resemblance  to  acute  hydrocephalus. 

"  In  the  first  stage  the  infant  becomes  irritable,  restless,  and  feverish  ; 
the  face  is  flushed,  the  surface  hot,  and  the  pulse  frequent ;  there  is  an 
undue  sensitiveness  of  the  nerves  of  feeling,  and  the  little  patient  starts 
on  being  touched,  or  from  any  sudden  noise ;  there  is  sighing,  and  moan- 
ing during  sleep,  and  screaming ;  the  bowels  are  flatulent  and  loose,  and 
the  evacuations  are  mucous  and  disordered.  If  through  an  erroneous 
notion  of  this  affection  nourishment  and  cordials  be  not  given,  or  if  the 
diarrhoea  continue  either  spontaneously  or  from  the  administration  of  medi- 
cine, the  exhaustion  which  ensues  is  very  apt  to  lead  to  a  very  different 
train  of  symptoms.  The  countenance  becomes  pale,  the  cheeks  cool  or 
cold  ;  the  eyelids  are  half  closed,  the  eyes  are  unfixed  and  unattracted  by 
any  object  placed  before  them ;  the  pupils  are  unmoved  on  the  approach 
of  light ;  the  breathing,  from  being  quick,  becomes  irregular,  and  affected 
by  sighs  ;  the  voice  becomes  husky,  and  there  is  sometimes  a  husky  teaz- 
ing  cough  ;  and  evidently,  if  the  strength  of  the  little  patient  continues  to 
decline,  there  is  crepitus  or  rattling  in  the  breathing ;  the  evacuations  are 
usually  green  ;  the  feet  are  apt  to  be  cold." 

It  is  my  opinion  that  this  form  of  disease  is  very  much  more  common 
than  it  is  supposed  to  be,  and  that  many  deaths  usually  reported  as  maras- 
mus are  evidently  of  this  nature. 

Of  local  cerebral  anaemia  I  will  speak  in  another  chapter. 

1  Op.  cit.,  p.  181. 


116  DISEASES   OF    THE    CEREBRUM    AND    CEREBELLUM. 

Causes. — As  causes  of  cerebral  anosmia  We  may  roughly  class  all 
agents  that  interfere  with  the  cerebral  blood-supply,  and  consider  them  as 
remote  or  local.  Whether  the  fault  lies  in  a  diseased  heart,  which  is 
unable  to  supply  the  brain  with  its  normal  amount  of  blood,  or  whether 
there  is  some  mechanical  obstruction  through  pressure  upon  the  cerebral 
arteries,  the  morbid  condition  is  the  same.  By  far  the  most  common  cause 
of  this  cerebral  condition  is  a  general  anaemia  which  may  be  dependent 
upon  a  number  of  conditions  which  drain  the  vessels.  Among  these  may 
be  enumerated  uterine  hemorrhages  of  various  kinds,  hemorrhoidal  fluxes, 
cancers  and  other  diseases  attended  by  hemorrhage,  as  well  as  general  dis- 
eases of  assimilation  which  prevent  the  proper  enrichment  of  the  blood. 
A  very  slight  reduction  in  the  quantity  of  the  blood  will  be  followed 
usually  by  indications  of  the  want  felt  by  regions  deprived  of  their  nourish- 
ment ;  but  when  the  nervous  system  suffers  this  deprivation,  the  loss  is 
immediately  shown.  Ilaller  has  calculated  that  one-fifth  of  all  the  blood 
in  the  body  is  sent  to  the  brain,  and  with  this  fact  in  view,  it  will  not  be 
difficult  to  realize  how  any  modification  of  circulation  will  result  in  im- 
mediate changes.  Heart  disease  generally  in  the  form  of  fatty  enlarge- 
ment, when  there  is  mitral  stenosis,  or  when  functional  activity  is  interfered 
with  by  emotional  or  other  causes,  may  have  much  to  do  with  cerebral 
anaemia.  This  cause  enters,  perhaps,  more  extensively  into  the  production 
of  chronic  cerebral  anaemia  than  any  other.  Owing  to  the  delicate  arrange- 
ment of  the  vaso-motor  nerves  which  so  beautifully  control  the  supply  of 
cerebral  blood, when  through  emotional  or  other  causes  the  function  is  altered, 
there  will  be  immediate  intra-  as  well  as  extra-cranial  anasmia.  We  have 
all  seen  that  sudden  emotions  not  only  blanch  the  face,  but  as  well  produce 
faintness.  Various  modifications  of  the  functions  of  the  liver  may  be  as- 
sociated with  states  of  cerebral  anaemia  through  modification  of  function 
of  this  system  of  nerves.  Milner  Fothergill  has  pointed  out  the  association 
between  the  nerves  of  this  organ  and  those  which  supply  the  vertebral  arte- 
ries ;  and  Schrucder  Van  der  Kolk  and  Laycock  have  said  that  those  parts 
of  the  brain  supplied  by  the  vertebral  arteries  were  the  seat  of  the  emo- 
tions. Fothergill  reminds  us  of  the  fact  that  we  may  have  functional  de- 
rangement of  the  liver  without  affection  of  the  intellect,  but  with  depressed 
emotional  states.  There  are  other  forms  of  abdominal  trouble,  such  as  an 
overloaded  rectum  and  uterine  derangement,  which  coexist  with  melancholia 
and  depression  of  spirits,  and  every  practitioner  has  seen  the  wonderful 
elation  of  spirits  which  follows  a  free  movement  of  the  bowels  after  con- 
tinued torpidity  of  the  liver.  The  extension  of  the  cerebral  vaso-motor 
and  the  involvement  of  other  areas  of  blood-supply  may,  of  course,  make 
the  condition  a  more  extensive  one,  and  disturbances  of  motility  and  in- 
tellection naturally  ensue. 

Pressure  made  upon  the  carotid  or  vertebral  arteries  by  various  tumors 
or  growths,  or  sometimes  by  aneurisms,  is  a  mechanical  cause  of  cerebral 
ana:mia  of  decided  importance.  I  assisted  at  an  operation  several  years 
ago  where  the  carotid  on  one  side  was  tied  by  Drs.  Sands  and  Parker,  of 
this  city.  In  less  than  twenty-four  hours  the  patient  died  from  extensive 


CEREBRAL    ANAEMIA.  U7 

anaemia.  Embolism  is  perhaps  the  simplest  example  of  a  cause  of  this 
kind.  A  detached  vegetation  or  clot  is  washed  into  the  circulation,  up 
through  the  left  carotid  and  into  the  middle  cerebral  artery  for  instance, 
cutting  off  the  circulation,  and  producing  extensive  cerebral  anaemia  on  the 
left  side,  while  right  hemiplegia  and  aphasia  follow.  In  thromoosis  the 
artery  is  narrowed  by  the  gradual  deposit  of  plastic  substance  until  finally 
its  calibre  is  occluded,  and  the  blood  must  take  some  other  channel  or  not 
reach  the  part  which  it  normally  supplied. 

Apoplexy,  or  brain  tumors  of  various  kinds,  and  atheromatous  narrowing 
of  cerebral  arteries,  are  also  direct  causes.  In  the  first  two  instances  pres- 
sure is  made  directly  upon  the  brain  substance,  and  in  the  latter  there  is 
a  gradual  change  in  the  vessels  themselves. 

As  a  familiar  illustration  of  how  cerebral  anaemia  may  be  produced  by 
a  drain  upon  the  general  vascular  system,  I  may  allude  to  the  case  of  a 
patient  whose  trouble  dated  from  a  series  of  miscarriages  occurring  within 
a  very  short  period.  One  of  these  happened  when  it  was  impossible  to 
procure  medical  attendance,  and  she  lost  a  great  quantity  of  blood. 

After  the  last  event  she  never  completely  recovered,  and  her  present 
disagreeable  and  annoying  condition  remained.  She  was  drowsy,  had 
frontal  headache,  ringing  in  the  ears  ;  was  constipated,  etc.  Another  pa- 
tient was  subject  to  attacks  of  despondency,  when  life  seemed  very  dis- 
tasteful and  gloomy.  Her  appearance  was  characteristic.  White  skin,  cold 
hands,  palpitation,  and  other  symptoms  enabled  me  to  diagnose  cerebral 
anaemia,  and  vomiting  and  vertigo  were  confirmatory  symptoms.  The  cause 
was  found  to  arise  from  very  troublesome  hemorrhoids.  After  cauteriza- 
tion and  removal,  she  regained  her  previous  health. 

Certain  medicinal  agents,  as  well  as  tobacco,  produce  cerebral  anaemia. 
The  bromides  undoubtedly  possess  this  property,  while  chloral  and  chlo- 
roform, if  taken  for  a  long  time,  as  they  often  are,  are  likely  to  provoke 
an  anaemic  state  of  the  brain  which  is  distressing  in  the  extreme.  I 
can  recall  the  case  of  a  young  lady  who  confessed  that  she  had  been 
in  the  habit  of  putting  herself  to  sleep  at  night  with  chloroform,  besides 
inhaling  it  several  times  during  the  day.  I  have  never  seen  such  a 
typical  case  of  this  morbid  condition.  Her  skin  was  of  a  hue  of  waxy 
whiteness,  her  pulse  small  and  fluttering,  her  pupils  widely  dilated,  and 
her  languor  and  muscular  feebleness  very  profound.  Depression  and  the 
contemplation  of  suicide  prompted  her  to  confess  her  bad  habit.  Tobacco, 
though  only  affecting  the  heart  through  its  interference  with  pulmonary 
functions,  undoubtedly  produces  in  some  individuals  a  condition  of  cerebral 
ana?mia.  The  clammy,  white  skin,  giddiness,  dilated  pupils,  hurried 
respiration,  and  unsteady,  weak  pulse,  and  not  uncommonly  syncope,  are, 
I  think,  evidences  of  cerebral  anaemia.  Certainly  the  after  effects  are 
clearly  suggestive  of  this  morbid  cerebral  condition.  That  tobacco,  in 
many  individuals,  in  fact  the  great  proportion,  possesses  stimulating 
effects,  there  can  be  no  doubt ;  but  the  variation  of  effects  which  follow 
the  administration  of  opium,  for  example,  when  there  is  some  idiosyn- 
crasy, clearly  leads  us  to  infer  that  its  action  is  sometimes  different  from 


118  DISEASES   OF    THE    CEREBRUM    AND    CEREBELLUM. 

that  determined  by  the  majority  of  physiologists.  Physostigtna,  aconite, 
and  other  cardiac  sedatives  may  be  mentioned  as  other  anaemiants. 

Various  conditions,  when  the  blood  is  poisoned,  such  as  lithiasis.  are 
sometimes  unsuspected,  but  nevertheless  very  important  causes  of  cerebral 
ana-mia. 

Morbid  Anatomy  and  Pathology — As  we  might  expect,  the 
anaemic  brain  is  white,  firm,  reduced  in  bulk,  and  greatly  changed.  The 
vessels  are  empty,  and  there  are  no  puncta  visible  when  a  cut  is  made 
through  the  white  matter.  We  may  find  a  distension  of  the  perivascular 
spaces  by  fluids,  and  occasionally  some  thickening  of  the  neuroglia. 

I  have  spoken  in  another  chapter  of  the  circumstances  which  modify 
the  cerebral  circulation.  It  only  remains  for  me  to  refer  to  the  experi- 
ments of  Kausmall  and  Tenner,  Burrowes,  and  others,  who  have  devoted  a 
great  deal  of  attention  to  the  experimental  study  of  this  subject.  The  ex- 
periments of  the  first  two  observers  were  made  upon  six  adults  and  a  number 
of  rabbits.  When  the  carotids  of  the  human  subject  were  compressed,  pallor, 
loss  of  consciousness,  slow  respiration,  and  dilated  pupils  were  produced, 
which  disappeared  when  the  pressure  was  remitted,  and  could  again  be 
produced  at  will.  Tying  of  the  carotids  was  followed  by  convulsions,  un- 
consciousness, and  death,  when  post-mortem  examination  revealed  evi- 
dences of  softening. 

In  the  first  experiments,  when  pressure  was  remitted,  there  were  evi- 
dences of  a  secondary  cerebral  hyperaemia  with  flushing  of  the  face.  Ob- 
struction of  tlie  artery  on  one  side  may  produce  loss  of  motor  power  on 
the  other,  with  immediate  giddiness,  loss  of  consciousness,  syncope,  and 
occasionally  vomiting.  There  may  be  complete  recovery  after  such  an 
accident,  but  "  it  is  always  imperfect  when  the  obstruction  is  situated  on 
the  further  side  (from  the  heart)  of  the  circle  of  Willis."1  The  obstruc- 
tion of  the  minor  cerebral  arteries  is  followed  by  less  complete  intellectual 
derangement,  by  more  marked  vomiting  and  giddiness.  Should  the  ante- 
mia  be  quickly  produced,  as  it  is  when  severe  injuries  have  been  received 
and  the  patient  literally  "bleeds  to  death,"  convulsions  form  a  prominent 
and  almost  constant  symptom.  Sighing  respiration,  and  the  other  phe- 
nomena I  have  already  named,  are  also  expressed. 

In  cerebral  ana-mia  there  is  impairment  of  functional  activity,  while  in 
congestion  the  reverse  is  the  rule.  Post-mortem  examination  shows  that 
the  brain  in  cerebral  anaemia  is  white,  condensed,  and  less  bulky,  and 
the  vessels  are  empty. 

We  have  already  cited  the  causes  of  cerebral  anaemia,  and  it  now  re- 
mains for  us  to  consider  the  part  they  play.  Cerebral  anaemia  depends 
upon — 

1.  The  insufficiency  of  cerebral  blood-supply  through  actual  deficiency. 

2.  The  action  of  certain  agents  upon  the  nerve-filaments  themselves. 

It  is  hardly  necessary  to  again  more  than  allude  to  the  first  of  these. 
In  this  condition  the  effect  of  posture  is  said  to  greatly  influence  the  cere- 


1  H.  Jones,  Functional  Nervous  Disorders,  p.  66. 


CEREBRAL    ANEMIA.  119 

bral  state.  The  erect  position  is  conducive  to  an  aggravation  of  the 
symptoms,  while  recumbency  favors  the  flow  of  blood  to  the  brain.  This 
relief  follows  the  supine  position  when  the  individual  has  an  ordinary 
attack  of  syncope.  Abercrombie  relates  a  case  which  is  quoted  by  Foth- 
ergill,  and  which  is,  I  think,  a  beautiful  practical  example  of  this  change. 
The  patient,  who  was  greatly  reduced  by  some  gastric  disease,  gradually 
became  deaf,  but  heard  perfectly  well  when  he  lay  down  or  stooped  forward. 
As  soon  as  his  face  became  flushed,  the  improvement  in  hearing  began,  and 
when  he  raised  his  head  the  blush  faded  away,  and  he  relapsed  into  his  old 
condition.  Abdominal  paracentesis  is  followed  by  syncope,  if  the  patient  is 
not  made  to  assume  the  supine  position,  for  during  ascites  the  abdominal 
veins  are  so  impinged  upon  that  when  pressure  is  remitted  they  are  capa- 
ble of  receiving  a  very  large  quantity  of  blood — in  fact,  so  much  as  to 
deprive  the  brain,  and  produce  the  anaemia.  A  quantity  of  blood  gravi- 
tates directly  through  the  superior  and  inferior  venae  cavae,  not  being 
thrown  over  by  the  right  ventricle,  but  passing  down  into  the  abdominal 
vessels. 

Insufficiency  of  cerebral  blood  may  be  due  to  a  powerless  heart,  that 
organ  being  unable  to  lift  a  requisite  amount  of  blood  for  the  nutrition 
of  the  brain.  Not  only  may  this  be  a  direct  result  of  a  weakened  organ, 
but  it  may  follow  strong  emotional  excitement. 

This  assumption  of  the  recumbent  posture  is  one  of  the  best  thera- 
peutical means  in  certain  cases.  Dr.  Weir  Mitchell  has  had  extraordinary 
success  in  the  management  of  certain  intractable  cases,  some  of  which 
were  directly  dependent  upon  cerebral  anosmia. 

Of  the  second  mode  of  production,  I  may  allude  to  the  local  effect  of 
some  blood  poisons,  and  the  influence  of  the  emotions.  Bearing  in  mind 
the  important  physiological  law  that  section  of  the  sympathetic  is  followed 
by  vascular  dilatation,  and  that  irritation  of  the  proximal  end  produces 
contraction,  we  are  enabled  to  realize  many  of  the  pathological  processes 
which  occur  in  the  production  of  cerebral  anaemia.  Anteriorly  the  vaso- 
motor  fibres  are  derived  from  the  superior  cervical  ganglion,  and  poste- 
riorly the  fibres  come  from  the  inferior  cervical  ganglion.  These  fila- 
ments follow  the  course  of  the  large  cerebral  vessels,  and  in  this  manner 
supply  every  part  of  the  cerebral  mass. 

This  close  relation  with  the  vascular  system  explains  the  prompt  action 
upon  the  heart  of  certain  exciting  emotions,  and  secondarily  the  variation  in 
blood-supply.  This  is  the  idea  held  by  Fothergill  and  others,  and  most  ad- 
mirably explained  by  that  writer  in  an  article  in  the  West  Riding  Reports.1 

The  connection  between  variation  in  cell  action  and  the  function  of 
the  sympathetic  fibres  is,  perhaps,  the  most  interesting  part  of  the  subject. 
Primarily  the  influence  of  impoverished  blood'  affects  the  integrity  of  the 
cerebral  nerve-cells,  and  secondarily  the  influence  of  the  cerebro-spinal 
fibres  is  suspended.  I  have  no  doubt  that  a  certain  train  of  symptoms, 
which  is  sometimes  expressed  during  general  anaemia,  is  the  result  of  a 

1  Art.  Cereb.  Anaemia,  vol.  iv.  p.  108. 


120  DISEASES   OF    THE    CEREBRUM    AND    CEREBELLUM. 

temporary  locsil  hypenemfo,  through  paresis  of  the  vaso-motor  fibres  ;  and 
that  parts  of  the  brain  are  congested  while  others  are  anaemic. 

A  result  of  continued  emptiness  of  the  vessels  is  an  oedematous  condition 
of  the  brain,  from  distension  of  the  peri  vascular  spaces  by  the  cerebro- 
npinal  fluid.  This  condition  is  sometimes  so  extensive  as  to  receive  the 
name  "  serous  apoplexy/'  and  profound  stupor  is  the  result. 

In  relation  to  sleep  and  its  connection  with  cerebral  ana-mia,  it  will  be 
well  to  say  a  few  words.  A  great  many  observers,  among  whom  were 
Durham,  Kausmall,  Tenner,  and  Fleming,  strongly  held  that  the  brain 
wsis  ana>mic  during  repose,  the  anaemia  being  the  cause  of  sleep.  Others 
have  differed  with  them;  but  experimental  facts  seem  to  favor  this  view  of 
the  case.  Not  only  may  anaemia  be  unattended  by  sleep,  but  a  condition 
of  unconsciousness  closely  resembling  healthy  sleep  may  be  the  result  of 
a  hyperaemic  cerebral  state.  Opium,  alcohol,  and  various  agents  which 
increase  the  cerebral  blood-supply,  act  in  this  way ;  but  the  stupor  which 
follows  a  toxic  dose  of  either  agent  must  not  be  confounded  with  natural 
sleep.  Certain  curious  facts  militate  strongly  against  the  anaemic  idea, 
or,  at  least,  against  the  assertion  that  sleep  is  directly  dependent  upon  a 
diminution  in  the  supply  of  blood  to  the  brain. 

1.  There  are   many  anaemic   individuals  who  sleep  only  after  taking 
stimulants.     I  think  all  who  have  seen  the  good  effects  of  a  bottle  of  ale 
at   bedtime  will  be  disposed  to  take  this  view.     The  sleep  produced  in 
no  way  resembles  stupor,  and  there  is  no  disagreeable  sense  of  fatigue  in 
the  morning. 

2.  My  friend,  Dr.  Janevvay,  has  called  my  attention  to  an  experiment 
he  has  made.     This  consists  in  the  administration  of  a  few  drops  of  nitrite 
of  amyl  to  a  sleeping  person.     Although  cerebral  congestion  follows,  the 
patient  does  not  awake. 

3.  If  mental  action  is  dependent  upon  activity  of  the  cerebral  circula- 
tion, and  sleep  upon  anaemia,  it  almost  seems  that  dreams  must  be  incon- 
sistent with  sleep  ;  while,  on  the  contrary,  many  individuals  enjoy  the  most 
vivid  and  constant  dreams,  and  do  not  awake  till  their  usual  hour. 

I  am  more  inclined  to  think  that  the  production  of  sleep  depends  upon 
some  change  in  the  function  of  the  nerve-cell,  and  that  this  modified  form 
of  action  is  not  necessarily  dependent  upon  either  anemia  or  congestion  in 
any  particular  case,  but  that,  if  there  be  aneemia,  it  is  secondary  to  the  cell- 
change,  whatever  that  may  be. 

The  connection  of  a  torpid  condition  of  the  liver  with  cerebral  anaemia 
will  explain  the  constipation,  which  is  anything  but  an  uncommon  accom- 
paniment of  the  disease.  Intestinal  accumulation,  as  Fothergill  says, 
may  "  stand  to  cerebral  anaemia  in  a  causal  as  well  as  a  consequential  re- 
lationship," and  he  alludes  to  the  experiments  of  Ludwig  and  Daziel  to 
illustrate  the  connection.  A  finger  passed  over  the  intestines  produced 
acceleration  of  the  intracranial  circulation. 

The  general  symptoms,  such  as  languor,  the  various  modifications  of 
sensation,  etc.,  are  directly  due  to  a  diminution  in  nervous  supply. 

Diagnosis — Acute  general  attacks  of  cerebral  anaemia  may  be  con- 


CEREBRAL    ANAEMIA.  121 

founded  with  cerebral  congestion,  stomachic  and  auditory  vertigo.  I  have 
already  spoken  of  the  distinction  to  be  made  between  the  disease  under 
discussion  and  cerebral  hypersemia,  and  it  is  not  necessary  to  say  more. 
Attacks  of  stomachic  vertigo,  or  Meniere's  disease,  are  symptomatized 
as  follows  :  The  first  is  characterized  by  a  feeling  of  "  emptiness  of  the 
head,"  reeling  and  swimming,  general  coldness  ;  "  objects  whirl  around  ;" 
no  loss  of  consciousness,  nor  marked  disposition  to  sleep.  No  dependence 
upon  a  very  full  or  empty  stomach,  and  the  possible  existence  of  gastral- 
gia.  In  Meniere's  disease  there  is  aural  disease,  and  turning  or  whirling 
generally  to  one  side,  from  left  to  right,  and  the  condition  is  not  continu- 
ous. The  most  important  facts  to  discover  are  in  relation  to  the  cause, 
whether  it  be  a  secondary  condition,  the  result  of  cardiac  trouble,  or 
whether  it  be  simply  a  result  of  general  anaemia,  without  any  organic 
disease. 

Chronic  cerebral  anaemia  presents  various  phases,  and  it  is  almost 
impossible  to  go  over  the  long  list  of  general  diseases  which,  like  hysteria, 
it  may  counterfeit. 

Prognosis. — As  cerebral  anaemia  is  nearly  always  due  to  some  cause 
which  is  easy  of  removal,  the  prognosis  is  good.  If,  however,  there  be 
organic  heart  trouble,  the  case  assumes  a  different  aspect.  Old  cases  are 
extremely  discouraging,  particularly  when  the  patients  happen  to  be  women. 
Irritability  and  hysteria  generally  enter  largely  into  the  complaint,  and 
treatment  is  sometimes  almost  useless.  If  uterine,  hemorrhoidal  fluxes, 
and  other  such  drains  exist,  of  course  their  amelioration  is  attended  by 
cure.  Should  the  loss  of  blood  be  caused  by  a  cancerous  uterus  or  rectum, 
the  prognosis  is  consequently  very  bad. 

Treatment It  is  of  the  utmost  importance  that  the  practitioner 

should  seek  out  and  remove,  if  possible,  such  conditions  as  diminish  the 
amount  of  blood  in  the  body,  and  consequently  he  must  ascertain  the  exist- 
ence of  hemorrhoids,  uterine  hemorrhages,  either  periodical  or  irregular, 
and  apply  appropriate  remedies  in  such  cases.  Without  venturing  upon 
another  field,  I  would  call  attention  to  the  necessity,  in  cases  where  there 
is  menorrhagia,  of  overcoming  this  condition  as  promptly  as  possible,  for 
special  treatment  of  the  nervous  condition  is  of  little  avail  when  the 
woman  every  month  loses  a  quantity  of  blood  largely  in  excess  of  what  is 
made  in  the  interim. 

Active  measures  are  necessary  when  there  is  general  anaemia,  and  for 
this  purpose  we  must  resort  to  iron,  strychnia,  phosphorus  in  some  of  its 
forms,  cod-liver  oil,  an  abundance  of  nutritious  food,  with  stimulants  such 
as  milk  punches,  porter,  or  ale  (FF.  8,  9,  10,  24,  29). 

A  word  or  two  is  necessary  in  regard  to  the  diet,  and  the  quantity  of  alco- 
hol given  to  these  patients.  It  is  the  physician's  bad  fortune  to  meet  with 
cases  of  this  kind  in  which  digestive  troubles  are  dependent  entirely  upon  an 
enfeebled  state  of  the  viscera,  and  we  should  therefore  use  great  care  and 
not  be  impatient.  A  hearty  regimen,  and  too  much  alcohol,  may  do  mischief 
instead  of  good.  It  is  well,  therefore,  in  certain  cases,  to  give  the  stomach 
as  little  work  as  possible,  and  at 'the  same  time  to  allow  it  to  exert  itself 


122  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

in  a  way  that  will  most  benefit  its  possessor.  A  very  little  food,  given  at 
short  intervals,  will  be  more  perfectly  digested  and  assimilated  than  a 
large  quantity  taken  at  long  intervals.  I  have  often  given  a  few  table- 
spoonfuls  of  cream  or  beef-juice  every  hour  for  days,  and  have  ultimately  seen 
such  a  marked  improvement  and  an  increased  capacity  for  work  upon  the 
part  of  the  digestive  organs,  that  the  more  gross  varieties  of  animal  food, 
as  well  as  alcohol,  were  after  a  while  borne  in  large  quantities.  Should 
this  enfeeblement  of  the  digestive  organs  exist,  we  may  give  either  pan- 
creatine  emulsion,  or  strychnia  and  muriatic  acid  (FF.  31,  33,  34).  Ex- 
tract of  malt  is  sometimes  very  well  borne,  and  hastens  the  improvement. 
This  may  be  given  in  combination  with  cod-liver  oil  (F.  32). 

One  of  the  most  useful  forms  of  treatment  to  which  I  have  already 
alluded — the  "  rest  treatment"  of  \Veir  Mitchell — is  of  marked  service 
in  old  cases,  especially  if  the  subjects  happen  to  be  women.  Dr.  Mit- 
chell has  treated  many  cases  which  are  almost  identical  with  those  that 
generally  come  under  the  head  of  chronic  cerebral  anaemia.  He  says : 
'»  These  cases  vary,  of  course,  endlessly  ;  but  their  essence  is  a  state  of 
reduced  nutrition,  which  no  mere  tonic  will  cure,  while  they  are  afoot  and 
Jiving  on  their  capital.  The  main  symptoms  are  the  state  of  painful  tire, 
the  low  temperature,  the  great  or  less  anaemia,  the  quick  pulse,  the  excess 
of  white  blood."  lie  calls  attention  to  the  necessity  for  perfect  quiet,  and 
at  the  same  time  daily  massage  and  faradization  of  all  the  muscles.  His 
treatment  is  expressed  in  his  own  words  thus  :  "  The  amount  of  feeding, 
of  massage,  and  of  faradic-muscle  exercise  which  each  case  will  bear  and 
prosper  under,  is  a  matter  to  be  told  early  in  the  case  by  watching  the 
pulse,  the  temperature,  and  the  appetite.  In  these  cases  the  pulse  is 
always  rapid.  If  it  fall,  if  the  temperature  rise,  above  all,  if  there  be  the 
least  gain  in  flesh,  I  know  that  I  am  on  the  right  path,  and  am  not  moving 
on  it  too  fast ;  but  if  these  symptoms  be  reversed,  and  if  the  patient  ceases 
to  be  hopeful  and  looks  weary,  then  I  lessen  the  passive  exercise,  and  wait 
a  little  ;  but,  above  all,  I  listen  to  what,  my  masseur  or  masseuse  tells  me 
of  the  ease  with  which  the  limbs  flush  or  the  readiness  with  which  the 
muscles  grow  firm  under  the  kneading  fingers,  for  in  this  matter  I  get  to 
have  a  very  shrewd  judgment.  As  to  the  rectal  feeding,  which  I  rarely 
omit.  I  say  little,  as  it  is  well  understood.  It  should  always  include  cod- 
liver  oil.  There  is  only  this  to  be  borne  in  mind:  most  medical  men  feed 
by  the  bowel  when  they  cannot  by  the  mouth.  I  like  to  use  both  ends  at 
once." 

This  treatment  seems  to  be  the  very  best  in  cases  of  long  standing ;  but 
it  is  well  to  see  first  what  fresh  air,  tonics,  and  abundant  nitrogenous  food 
will  do  for  our  patient,  while  she  pursues  her  ordinary  life. 

I  have  lately  modified  Mitchell's  treatment,  and  have  placed  my  patient 
in  a  darkened  room.  This  condition,  which  is  attended  by  excitement 
and  irritability  of  the  organs  of  special  sense,  is  much  benefited  by  abso- 
lute quiet,  and,  therefore,  darkness  and  rest  are  most  agreeable  and  useful 
forms  of  treatment. 


STOMACHIC    VERTIGO.  123 


STOMACHIC  VERTIGO. 

Synonyms — Vertigo  a  stomacho  laeso  (Lat.) ;  Vertige  stomacal  (Fr.)  ; 
Gastric  vertigo. 

Definition. — A  condition  of  giddiness,  hallucination,  nausea,  head- 
ache, etc.,  without  loss  of  consciousness,  and  probably  dependent  upon  a 
reflex  excitation  of  the  cerebral  vessels  from  some  visceral  irritation. 

Symptoms. — The  condition,  which  is  a  very  common  one,  is  pro- 
duced, in  most  cases,  directly  after  a  hearty  meal,  or  else  when  the 
stomach  is  entirely  empty.  A  sense  of  gastric  fulness  at  first,  while  head- 
ache, with  buzzing  in  the  ears,  palpitation,  and  giddiness  of  a  few  mo- 
ments' duration,  follow.  Should  there  be  hallucinations,  the  patient  is 
not  worried  by  them,  but  realizes  their  unsubstantial  character.  Trous- 
seau1 insists  upon  the  fact  that  the  hallucinations  of  this  condition  differ 
from  those  attendant  upon  cerebral  hypenemia  from  the  fact  that  in  this 
form  they  do  not  occur  when  the  head  is  lowered,  which  is  the  case  in 
cerebral  hyperoemia. 

Causation Stomachic  vertigo  is  more  a  condition  of  middle  life  and 

old  age  than  one  of  youth.  Young  women  occasionally  suffer,  but  this  is 
the  exception.  Certain  forms  of  indigestible  food  may  directly  provoke 
the  attack,  or  it  may  follow  violent  exercise  after  a  hastily  eaten  meal. 
In  one  case  of  which  I  know,  a  gentleman  ran  for  over  a  mile  to  catch  a 
morning  train.  He  had  arisen  but  a  few  moments  before,  and  had  hurri- 
edly eaten  his  breakfast.  He  fell  to  the  ground,  but  did  not  lose  con- 
sciousness. The  disorder  often  occurs  when  the  individual  has  been  eating 
irregularly;  and  business  men  or  others  who  take  but  little  exercise  and 
eat  hurriedly  are  very  often  the  sufferers.  Handfield  Jones2  considers  taenia 
to  be  a  frequent  cause  of  vertigo,  and  such  has  been  my  own  experience. 

Treatment Trousseau,  who  has  written  most  fully  upon  the  sub- 
ject, recommends  that  the  patient  be  directed  to  drink  every  morning  a 
glassful  of  quassia  infusion  made  by  maceration  of  the  shavings  in  water, 
or  to  use  the  goblet  of  quassia  wood  in  which  the  water  is  allowed  to  re- 
main until  it  has  become  bitter.  After  each  meal  one  of  these  powders 
should  be  taken : — 

R.   Sodae  bicarb., 

Magnesias  calc.,  aa  gr.  xv. 
Greta?  praep.  3ss. — M. 
Divid.  in  chart,  no.  iij. — Sig.    One  after  each  meal. 

Strychnia,  pepsine,  and  sometimes  bismuth  (FF.  30,31,  28)  are  excel- 
lent remedies,  and  should  be  given,  while  attention  is  to  be  paid  to  the 
patient's  general  habits. 

1  Clinical  Medicine,  Am.  edition,  vol.  ii.  p.  358. 

2  Functional  Nervous  Disorders,  p.  444. 


124  DISEASES   OF    THE    CEREBRUM    AND    CEREBELLUM. 

AUDITORY  VERTIGO. 

Synonyms Labyrinthine  vertigo  ;  MeV.ere's  disease. 

Definition — A  morbid  cerebral  condition  expressed  by  vertigo  and 
rotatory  movements,  unattended  by  loss  of  consciousness,  and  dependent 
upon  disease  of  the  labyrinth,  or  other  parts  of  the  central  auditory  appa- 
ratus. 

To  Mdn'ere1  belongs  the  credit  of  having  first  accurately  described  this 
disease,  though  Triquet2  gives  the  credit  of  its  discovery  to  Saissy,  of 
Lyons,  who  observed  a  nervous  condition  connected  with  diseases  of  the 
inner  ear.  Trousseau3  says  that  Saissy  did  not  mention  vertigo  as  a 
symptom  of  the  condition  to  which  he  called  attention.  It  is  enough  to 
say  that,  prior  to  1861,  the  form  then  known  only  as  stomachic  vertigo 
was  always  supposed  to  arise  from  digestive  troubles,  and  the  existence  of 
a  distinct  variety,  with  aural  disease,  was  not  appreciated. 

Symptoms Generally  there  are  some  indications  of  otitis,  whether 

they  be  simple  inflammation  denoted  by  pain,  or  a  discharge  of  bloody 
pus,  or  even  perforation  of  the  tympanum.  In  many  cases  the  disease 
may  be  preceded  by  a  chill,  and  this  should  be  always  looked  upon  as  a 
serious  indication.  The  patient  is  suddenly  seized  with  vertigo,  and  at 
the  same  time  experiences  a  feeling  of  nausea  and  buzzing  in  the  cars, 
which  may  be  double,  or  confined  to  one  side.  This  vertiginous  condi- 
tion calls  to  mind  a  sensation  experienced  when  one  is  twirled  in  a  swing. 
A  boyish  prank  is  to  twist  the  ropes  of  a  swing  while  the  unhappy  victim 
is  seated  therein;  then  to  suddenly  release  the  board,  which  revolves  with 
great  rapidity  as  the  ropes  unwind.  This  description  of  the  symptom  was 
given  me  by  a  patient  who  suffered  from  nausea  at  the  same  time  with 
vertigo.  The  vertigo  is  attended  by  a  loss  of  equilibrium.  The  patient 
sways  or  reels,  and  there  is  an  impulse  to  turn  from  the  left  to  right  when 
the  left  ear  is  affected,  and  vice  versa  when  the  other  is  the  seat  of  the 
disease.  Ferrier4  describes  a  sensation  usually  experienced.  He  (the 
patient)  feels  "as  if  he  were  suddenly  lifted  from  the  ground  and  pitched 
forward  and  to  the  right  side."  There  is  also  a  tendency,  when  walking, 
to  keep  close  to  the  side  of  the  wall  or  house  which  corresponds  to  the 
affected  ear.  Deafness  is  generally  present,  but  this  is,  of  course,  the 
result  of  the  destructive  aural  disease.6  Recovery  is  not  always  to  be 


1  Bulletin  de  1' Academic  de  M6rl.,  xxvi.  p.  241. 

2  LeQons  cliniques  sur  les  Maladies  de  1'Oreille,  p.  113,  Paris,  1863. 

3  Loc.  fit.,  p.  363. 

4  Labyrinthine  Vertigo,  W.  R.  Reports,  vol.  v.  p.  34. 

5  Crum-Brown  is  of  the  opinion  that,  in  addition  to  the  other  senses,  the  indi- 
vidual  possesses  one  of  rotation,  by  which  we  are  able  to  determine  the  axis 
about  which  rotation  of  the  head  takes  place ;  the  direction  of  rotation,  and  its 
rate.     In  explaining  some  experiments  performed  by  him,  he  says:    "  In  ordi- 
nary circumstances  we  do  not  wholly  depend  upon  this  sense  for  such  information. 
Sight,  hearing,  touch,  and  muscular  sense  assist  us  in  determining  the  direction 


AUDITORY    VERTIGO.  125 

expected,  but  a  great  many  cases  improve  under  appropriate  treatment 
presently  to  be  described. 

John  B.,  aged  47,  iron  railing  manufacturer.  Nearly  eighteen  months 
ago,  he  became  troubled  by  noises  in  the  left  ear,  which  he  compared  to 
the  "  singing  of  canary  birds,"  and  afterwards  this  subjective  noise 
changed  its  character,  and  he  described  it  as  a  continuous  roaring  like  the 
escape  of  steam  from  a  boiler.  To. this  sound  he  has  since  become  par- 
tially accustomed.  He  has  never  had  earache,  but  nine  years  ago  there  was 
a  discharge  from  the  left  ear,  but  there  have  since  been  no  other  symp- 
toms. He  has  suffered  for  a  long  time  from  post-pharyngeal  catarrh,  and 
there  is  now  a  catarrh  of  both  Eustachian  tubes.  When  a  young  man  he 
had  secondary  syphilitic  symptoms,  but  denies  having  had  any  primary 
sore.  Sixteen  months  ago,  during  hot  weather,  he  was  seized  in  the  street 
with  dizziness  and  reeling,  and  was  obliged  to  grasp  a  lamp-post  for  sup- 
port. There  was  no  loss  of  consciousness,  and  he  realized  fully  his  con- 
dition of  helplessness.  He  said  that  he  felt  as  if  he  was  being  "  twirled  " 
from  right  to  left,  but  did  not  fall.  This  attack  occurred  before  dinner 
(about  11  A.  M.),  and  his  stomach  was  neither  filled  nor  completely 
empty,  for  he  had  eaten  his  breakfast  at  8  A.  M.  He  was  perfectly  well 
otherwise,  and  the  only  disordered  function  was  that  of  the  lower  bowels, 
for  he  was  constipated.  He  has  had  these  attacks  very  frequently.  For 
the  six  months  following  the  first  attack  of  vertigo  they  occurred  about 
once  a  month,  but  since  then  they  had  been  of  daily  recurrence. 

Present  State. — The  patient's  digestive,  organs  are  in  good  condition, 
and  his  appetite  is  fair.  He  is  ordinarily  of  constipated  habit,  but  it  re- 
quires but  slight  medication  to  overcome  this.  He  is  of  medium  height, 
weighs  1  43  pounds,  and  seems  a  well-nourished  man.  His  face  is  some- 
what suffused  when  he  becomes  excited,  but  he  is  ordinarily  pale.  His 
eyes  convey  an  anxious  expression,  but  the  pupils  are  normal.  His  hair 
is  scanty  and  gray,  but  not  removed  in  patches,  nor  suggestive  of  any  pre- 
vious syphilitic  trouble.  He  has  occasional  headache,  and  still  complains 
of  the  "  roaring"  noise  on  the  left  side.  Hears  the  tick  of  a  watch  only 
six  inches  from  left  ear,  and  indistinctly  at  any  distance  within  this 
limit.  AVatch  tick  heard  at  five  inches  from  right  ear,  but  more  perfectly. 
Dr.  C.  S.  Bull  examined  his  eyes,  and  the  following  is  his  report : — 

and  amount  of  our  motions  of  rotation,  as  well  as  of  those  of  translation ;  but  if 
we  purposely  deprive  ourselves  of  such  aid,  we  find  that  we  can  still  determine 
with  considerable  accuracy  the  axis,  the  direction,  and  the  rate  of  rotation.  The 
experiments  that  I  have  made  with  the  view  of  determining  this  point  were  con- 
ducted as  follows :  A  stool  was  placed  on  the  centre  of  a  table  capable  of  rotating 
smoothly  about  a  vertical  axis;  upon  this  the  experimenter  sat,  his  eyes  being 
closed  and  bandaged ;  an  assistant  then  turned  the  table  as  smoothly  as  possible 
through  an  angle  of  the  sense  and  extent  of  which  the  experimenter  had  not  been 
informed.  It  was  found  that,  with  moderate  speed,  and  when  not  more  than 
one  or  two  complete  turns  were  made  at  once,  the  experimenter  could  form  a 
tolerably  accurate  judgment  of  the  angle  through  which  he  had  been  turned. 
By  placing  the  head  in  various  positions,  it  was  possible  to  make  the  vertical 
axis  coincide  with  any  straight  line  in  the  head.  It  was  found  that  the  accuracy 
of  the  sense  was  not  the  same  for  each  position  of  the  axis  in  the  head ;  and,  fur- 
ther, that  the  minimum  perceptible  angular  rate  of  rotation  varied  also  with  the 
position  of  the  axis.  It  was  also  found  that  considerable  differences  of  accuracy 
exist  in  different  individuals." 


126  DISEASES   OF    THE    CEREBRUM    AND    CEREBELLUM. 

20 
"  Examination  of  J.  B.     V—  ...     -;  with  convex  32  spherical  V 

H  —  .     Fundus  perfectly  normal." 
30 

His  attacks  occur  nearly  every  day,  and  seem  to  have  no  relation  with 
the  condition  of  digestion.  These  "  reeling  fits  "  may  take  place  at  any 
time  of  the  day,  last  for  five  or  six  minutes,  and  usually  are  not  so 
sudden  as  to  prevent  him  from  taking  hold  of  the  nearest  lamp-post  or 
railing.  In  a  recent  vertiginous  seizure  he  was  taken  just  as  he  was 
about  to  get  into  a  street  car,  and  would  have  fallen  had  the  conductor 
not  dragged  him  upon  the  step.  He  tells  me  that  he  has  asked  his  wife 
to  "  turn  him  the  other  way  "  when  the  attack  occurs,  and  usually  this  has 
the  effect  of  abating  it.  I  placed  him  upon  large  doses  of  quinine  at  first, 
which  have  decidedly  influenced  the  frequency  and  character  of  the  ver- 
tigo, so  that  he  often  passes  a  week  at  a  time  without  any  seizure.  Bro- 
mide of  potassium  had  been  prescribed  for  him  before  his  visit  by  another 
physician,  but  he  tells  me  that  this  drug  increased  the  dizziness.  The 
phenomena  of  these  attacks  are  the  following :  He  suddenly  feels  light 
headache  ;  objects  swim  about  him  from  right  to  left  while  he  seems 
to  be  rotated  the  other  way,  and  during  this  period  he  separates  his  feet 
and  braces  himself.  The  outlines  of  the  houses,  trees,  and  sidewalks  are 
blurred  and  distorted,  and  after  a  few  minutes  they  suddenly  assume  their 
proper  relations,  and  the  attack  passes  off,  and  he  has  subsequent 
headache. 

Causes — The  disease  being  directly  due  to  aural  inflammation,  and 
the  causes  of  this  condition,  whether  they  be  exposure,  the  extension  of 
other  inflammatory  processes,  or  the  injudicious  use  of  douches  and  injec- 
tion, are  only  secondarily  productive  of  the  neurosis. 

Pathology The  experiments  of  Flourens  and  Goltz'  have  been  the 

basis  for  our  pathological  study  of  Me*niere's  disease.  Brown-Se'quard* 
and  Flourens  demonstrated  that  when  the  membranous  canals  of  the 
labyrinth  were  divided,  various  disturbances  of  equilibrium  followed. 
"Walter  and  Lincke3  and  others  have  divided  the  horizontal  canals  and 
produced  oscillation  of  the  eyeballs,  swaying  of  the  head  from  one  side  to 
the  other;  and  have  seen  the  animal  spin  round  like  a  top.  Division  of 
the  posterior  vertical  canal  causes  the  animal  to  topple  over  backwards, 
and  the  head  is  moved  backwards  and  forwards.  When  the  superior  ver- 
tical canals  were  cut  across,  the  animal  pitched  forward.  It  may  be  seen 
that  a  diseased  condition,  not  limited  to  any  particular  spot,  may  produce 
a  combination  of  these  symptoms. 

Brown-Sequard,  in  speaking  of  the  relation  of  rotatory  movements  to 
auditory  irritation,  calls  attention  to  these  familiar  illustrations: — 

"  1st.  Any  one  who  has  received  an  injection  of  cold  water  in  the  ear 


1  PHuger's  Archiv  i'Ur  Physiologic,  1870,  and  Recherchcs  sur  les  Propr.  et  les 
Functions  du  Systferae  Nerveux,  2d  ed. 

2  Central  Nervous  System,  Philadelphia,  1860,  and  Experimental  Researches, 
1853. 

3  Wagner's  Handworterbuch  der  Physiol.,  vol.  vi.,  1853,  p.  420  et  seq. 


AUDITORY    VERTIGO,  127 

may  know  that  it  produces  a  kind  of  vertigo,  and  that  it  is  difficult  to  walk 
straight  for  some  time  after  this  irritation.     2d.  A  sudden  noise  makes  the 
whole  body  jump,  particularly  in  old  people,  or  in  persons  attacked  with 
anaemia,  chlorosis,  epilepsy,  chorea,  hysteria,  hydrophobia,  and  in  certain 
cases  of  poisoning ;  in  a  word,  in  all  circumstances  in  which  the  control  of 
the  will  over  reflex  actions  is  lost  or  diminished.     3d.  ATertigo  and  various 
convulsive  movements  in  cases  of  irritation  of  the  acoustic  nerve  have 
been  observed  in  adults  and  children.     Rotatory  movements  have  taken 
place  in  cases  of  suppurative  inflammation  of  the  ear,  and  twice  imme- 
diately after  an  injection  of  nitrate  of  silver."     Ferrier,1  who  has  written 
most  clearly  upon  this  disease,  goes  very  deeply  into  the  subject.     In  the 
normal  state  it  is  necessary  for  tactile,  visual,  and  auditory  impressions  to 
be  unembarrassed,  so  that  the  power  of  equilibriation  may  be  preserved  ; 
but  it  is  of  absolute  importance  that  the  labyrinthine  functions  should  be 
perfect.     It  seems  to  regulate  the  state  of  equilibrium  of  the  individual, 
and  to  preside  over  coordination.     The  mechanism  of  the  labyrinthine 
canals  is  admirably  described  by  Crum-Brown.2     The  sense  of  rotation, 
as  suggested  by  him,  must,  like  other  special  senses,  have  a  special  peri- 
pheral organ,  a  brain  centre,  and  a  connecting  sensory  nerve.    All  experi- 
menters agree  that  the  labyrinth   is  a  special  peripheral  organ,  and  the 
auditory  nerve  is  that  which  conveys  the  peripheral  irritation  to  the  centre. 
"  The  bony  canals  are  filled  with  liquid,  in  which  float  loose  connective 
tissue,  and  the  membranous  canals  with  the  contained  endolymph.     Rota- 
tion of  the  head  about  an  axis  at  right  angles  to  the  plane  of  a  canal  will 
then  produce,  on  account  of  the  inertia  of  the  liquid,  etc.,  motion  of  the 
contents  relatively  to  the  walls  of  the  canal ;  and  this  may  be  expected  to 
irritate  the  terminations  of  the  nerves  in  the  ampulla.     If  the  rotation  be 
continued  at  a  uniform  rate,  fluid  friction  of  the  endolymph  against  the 
membranous  canal,  and  of  the  perilymph  against  the  membranous  canal, 
and  the  periosteum  will  gradually  diminish  this  relative  motion,  which  will 
at  last  cease.     We   should  therefore  expect,  as  we  have  seen  to  be  the 
case,  that  continued  uniform  rotation  should  be  perceived  less  and  less 
.strongly,  and  that  the  sensation  should  at  last  die  away  altogether.     The 
time  required  for  this  equalization  of  the  motion  of  the  canal  and  its  con- 
tents will  depend  upon   the  rate  of  rotation  and  upon  the  dimensions  of 
the  canal  and  the  amount  of  attachment  of  the  membranous  canal  to  the 
periosteum.     These  latter  conditions  are  not  the  same  in  the  three  canals, 
and  therefore  we  ought  to  find,  as  we  do,  that  the  rate  at  which  the  sense 
of  rotation  dies  away  is  not  the  same  for  different  positions  of  the  head. 
Again,  if  the  uniform  rotation  is  stopped,  the  contents  of  the  canal  will 
continue  to  move  on,  thus  causing  an  apparent  rotation  in  a  direction  the 
reverse  of  that  of  the  original  rotation,  and  this  also  will  die  away  owing 
to  friction."     The  irritation  of  the  auditory  nerves  which  occurs,  is  at- 
tended by  anaemia  of  certain  parts  of  the  brain,  which  accounts  for  the 

1  Ferrier  on  the  Functions  of  the  Brain,  New  York,  187(3. 

2  Journal  of  Anatomy  and  Phys.,  May,  1874. 


128  DISEASES   OF    THE    CEREBRUM    AND    CEREBELLUM. 

reeling,  dizziness,  nausea,  and  other  symptoms  with  which  we  are  already 
familiar. 

Diagnosis. — (lowers,1  in  a  paper  before  the  British  Medical  Associa- 
tion, pointed  out  the  liability  of  its  confusion  with  gastric  trouble.  He 
calls  attention  to  the  fact  that  violent  and  repeated  vertiginous  attacks,  the 
sense  of  movement  or  actual  turning,  tinnitus  aurium,  and  deafness,  are 
more  suggestive  of  the  auditory  origin  than  of  gastric  vertigo.  Gowers' 
cases  were  connected  with  affections  of  smell  and  taste,  and  at  the  same 
time  in  one  there  was  a  gastric  ulcer.  He  made  his  diagnosis  by  the  de- 
tection of  loss  of  function  of  the  right  ear  and  by  one-sided  falling.  It  is 
often  necessary  to  differentiate  from  petit  mat,  from  apoplectic  warnings, 
and  from  general  cerebral  anaemia.  In  the  first  there  is  rarely  vertigo, 
but  there  is  loss  of  consciousness  of  temporary  duration,  and  there  is  some 
convulsive  movement,  though  sometimes  so  slight  as  to  be  unrecognized. 
The  presence  of  aural  disease  is  enough  to  throw  out  of  the  question  the 
other  condition  I  have  named. 

Treatment. — Large  doses  of  quinine  have  been  of  service  in  these 
cases,  and  CharcotV  experience  with  this  agent  is  extremely  gratifying. 

He  recommends  the  energetic  use  of  revulsives  in  vertigo,  the  cautery 
being  applied  over  the  mastoid  bone  three  or  four  times  a  week.  He 
gave  sixty  centigramme  doses  of  quinine  in  one  case  for  a  period  of  two 
months  with  happy  results,  and  a  short  time  after  the  commencement  the 
vertiginous  attacks  ceased.  It  is  necessary  to  give  the  drug  in  large 
doses,  and  at  the  same  time  the  aural  disease  should  not  be  neglected. 

In  the  case  of  "  J.  B."  I  combined  infusion  of  digitalis  with  the 
quinine,  and  obtained  very  good  results.  He  was  also  directed  to  turn 
in  an  opposite  direction  to  that  caused  by  the  disease.  Subsequent  expe- 
rience has  convinced  me  that  strychnine  is  perhaps  better  than  quinine, 
and  I  have  been  highly  successful  in  relieving  a  case  of  much  greater  vio- 
lence in  which  increasing  doses  of  the  drug  were  administered.  In  this 
connection  it  will  be  well  to  call  attention  to  attacks  of  malarial  vertigo  of 
a  periodic  character  which  are  sometimes  encountered,  and  which  re- 
semble auditory  vertigo:  quinine  or  arsenic  is  of  course  indicated. 

1  Br.  Med.  Journal,  Aug.  26,  187G. 

2  Lc'Qons  sur  les  Maladies  dti  Syst.  Nerv.  No.  4,  p.  321. 


INTRACRANIAL    THROMBOSIS  129 


CHAPTER    IY. 

OCCLUSION  OF  INTRACRANIAL  VESSELS. 

THROMBOSIS EMBOLISM. 

THE  deprivation  of  an  area  of  greater  or  less  extent  of  its  blood-supply 
constitutes  a  condition  which  has  been  called  by  some  writers  "  Local 
cerebral  anosmia,"  and  it  may  take  place  through  the  existence  of  either  of 
the  above  vascular  states.  Though  very  closely  allied,  these  two  forms  of 
mechanical  obstruction  may  be  defined :  in  one  case,  as  the  local  for- 
mation of  deposits,  or  morbid  changes  favoring  obliteration  of  bloodves- 
sels ;  and  in  the  other,  as  the  lodgment  of  clots,  or  organized  tissues  which 
have  been  brought  from  a  distance.  Their  chief  interest  lies  in  the  fact, 
that  it  is  often  difficult  for  us  to  distinguish  the  subsequent  symptoms 
from  those  indicating  an  effusion  of  blood  from  a  ruptured  vessel ;  that 
speech  troubles  are  prominent ;  and  that  the  prognosis  is  nearly  always 
unfavorable.  Thrombosis  and  embolism,  though  usually  followed  by  many 
of  the  same  symptoms,  and  confounded  with  each  other  by  some  of  the 
medical  writers  by  whom  they  were  first  described,  differ  greatly  in  their 
manner  of  occurrence  and  pathology.  The  first,  as  we  shall  hereafter  see, 
is  of  slow  development,  and  is  not  so  serious  in  its  results  as  embolism, 
while  the  latter  condition  is  much  more  grave  in  all  its  features. 

INTRACRANIAL  THROMBOSIS. 

Any  local  vascular  change  from  the  normal  state  which  favors  the  depo- 
sition of  fibrine  in  an  intracranial  vessel,  whether  it  be  an  artery,  a  vein, 
or  sinus,  produces  the  condition  which  is  known  as  thrombosis.  As  a  con- 
sequence, the  calibre  of  the  vessel  is  narrowed,  and  circulation  of  blood  is 
impeded  therein  ;  clots  form,  and  either  from  actual  obstruction  of  direct 
supply  or  by  pressure,  a  region  of  greater  or  less  extent  becomes  anaemic. 
Though  the  arteries  are  more  frequently  the  seat  of  such  an  alteration,  the 
veins  and  large  sinuses  and  the  capillaries  may  be  plugged  up  by  clots 
which  are  of  local  origin.  The  condition,  however,  last  mentioned  is  for- 
tunately a  very  rare  one,  but  when  it  is  met  with  it  is  a  most  dangerous 
and  alarming  morbid  state. 

THROMBOSIS  OF  THE  CEREBRAL  ARTERIES. 

Symptoms It  is  a  disease  of  slow  development,  and  may  affect 

several  arteries  simultaneously,  or  but  one.     For  weeks,  or  even  months 
9 


130  OCCLUSION    OF    INTRACRANIAL    VESSELS. 

before,  distressing  and  important  evidences  appear,  and  the  patient  may 
present  unmistakable  expression  of  the  cerebral  change,  such  as  headache, 
which  is  generally  localized,  confusion  of  ideas,  and  awkwardness  of 
speech,  these  disturbances  being,  usually,  varieties  of  aphasia.  As  the 
disease  advances  this  trouble  becomes  much  more  pronounced,  and  in 
place  of  there  being  simply  a  difficulty  in  expressing  a  clearly  origi- 
nated idea,  there  may  be  a  condition  of  amnesia.  Clumsiness  of  speech, 
and  want  of  delicacy  in  articulation  are  followed  by  an  actual  failure  in 
remembering  words.  Memory  is  also  defective  in  other  things,  and  our 
patient  begins  to  become  stupid  and  listless.  The  next  indication  of  this 
advance  may  be  the  appearance  of  paralysis,  which  is  sometimes  slight  or 
incomplete,  only  involving  the  muscles  of  the  face  or  eyeballs,  or  there 
may  be  hemiplegia.  Should  the  thrombus  be  seated  in  a  large  artery,  or 
softening  occur,  a  complete  and  lasting  hemiplegia  may  be  produced. 
There  is  rarely  loss  of  consciousness  at  any  time,  and  in  very  few  of  the 
cases  that  recover,  is  there  anything  at  all  like  the  paralysis  following 
cerebral  hemorrhage. 

Recovery  is  generally  to  be  looked  for,  provided  the  vessel  be  not  an 
important  one;  and,  though  like  its  first  cousin,  embolism,  it  may  be 
one  of  the  causes  of  softening,  such  a  termination  is  not  always  to  be 
feared.  Aphasia,  which  is  insisted  upon  by  most  writers  as  a  pathog- 
nomonic  sign,  is  occasionally  absent.  In  one  case  reported,  though  the 
left  middle  cerebral  was  affected,  there  was  no  aphasia  at  any  time.1 

The  following  case  is  one  that  came  under  my  observation,  and  is  of 
interest  because  of  the  seat  of  the  thrombus,  and  the  interesting  character 
of  the  morbid  appearances. 

L.  C.,  aged  22  years,  seamstress;  admitted  into  hospital  October  9, 
1876.  History  from  friend  who  accompanied  her.  The  patient  had  been 
feeling  unwell  for  about  two  months,  having  had  pains  in  her  head  and 
back,  loss  of  appetite,  insomnia,  and  other  troubles.  About  a  week  ago 
the  friend  went  up  to  her  room  to  assist  her  to  dress  for  breakfast.  When 
the  patient  stepped  out  of  bed  she  fell  upon  the  floor,  and  then  first  noticed 
that  she  was  completely  paralyzed  on  the  right  side.  The  friend  knew 
nothing  of  the  patient's  antecedents.  Her  husband,  who  was  seen  subse- 
quently, stated  that  he  had  left  her  because  she  drank ;  and  that  after  the 
separation  she  went  to  New  York  and  became  a  prostitute.  Two  years  ago 
he  saw  her,  and  at  that  time  she  had  marks  of  syphilis  on  her  face,  and 
her  hair  was  falling  out.  She  went  to  Ward's  Island  for  treatment.  She 
conversed  with  him  intelligibly,  but  said  she  was  suffering  from  "general 
debility."  She  had  headache,  pain  in  the  back,  etc.,  and  was  at  this  time 
leading  a  very  irregular  life;  sitting  up  during  the  greater  part  of  the 
night,  and  sleeping  only  a  portion  of  the  day.  The  following  history  was 
taken  by  Dr.  Naylor,  resident  physician  in  hospital: — 

Oct.  10.  Complete  hemiplegia  of  the  right  side,  limbs  lax,  and  muscles 
flabby;  impossible  to  excite  reflex  movements  by  tickling;  right  pupil 

1   St.  George's  Hospital  Reports,  vol.  i..  1866,  vol.  vi.  p.  322. 


THROMBOSIS    OF    CEREBRAL    ARTERIES.  131 

irregular,  and  smaller  than  the  left ;  tongue  drawn  to  left  side  when  pro- 
truded, and  when  she  laughs  the  right  side  of  the  face  is  drawn  up.  Con- 
trol over  the  sphincters  good;  temperature  101°  ;  patient  aphasic.  When 
asked,  "  How  long  have  you  been  sick?"  replied,  "Since  Benny;"  this 
answer  was  given  to  many  questions  asked.  "  What  do  you  hold  in  your 
hand?"  (it  was  a  piece  of  bread.)  "Tobacco."  Seemed  puzzled,  but 
when  reminded  of  its  true  nature  she  brightened  up  and  appeared  to  realize 
her  mistake. 

13th,  In  about  the  same  condition.  Muscles  of  the  right  arm  and  leg 
do  not  respond  to  the  currents.  When  asked  how  old  she  was,  replied, 
"  So  and  so."  "  What  did  you  work  at  ?"  "  So  and  so."  "  What  street 
did  you  live  in?"  Appears  puzzled.  "Was  it  sixteenth?  seventeenth? 
eighteenth?"  "Yes."  "How  long  has  it  been  since  you  last  saw  your 
mother?"  "  You  long  so,  John."  Expression  intelligent,  and  she  seems 
to  understand  all  that  is  said  to  her.  Does  not  hear  so  well  on  left  side, 
with  right  ear  perfectly. 

17th.  Appeared  to  be  suffering  great  pain.  When  asked  to  locate  the 
pain,  she  did  not  attempt  to  do  so.  She  has  passed  no  urine  since  yester- 
day morning.  Has  a  hard  and  swollen  erythematous  spot  on  the  outside 
of  each  knee,  and  two  similar  enlargements  on  each  leg  below.  There  is 
a  hardened  red  spot  over  the  fourth  cervical  vertebra.  All  of  these  parts 
are  painful  to  pressure.  . 

18th.  Right  hand  somewhat  swollen.  6P.M.  Is  drowsy  this  evening. 
Appears  to  suffer  pain,  and  places  left  hand  upon  abdomen.  One  pint  of 
straw-colored  urine  containing  no  abnormal  constituents  was  drawn  by  the 
catheter. 

19th.  Still  dull  and  drowsy.  Said  nothing  to-day  but  "  yes,"  "  no,"  and 
"  well ;"  passed  her  urine  in  bed ;  stupid  and  dull  all  day.  Carotid  on 
right  side  pulsates  very  distinctly. 

21st.  Somewhat  brighter  to-day  ;  bowels  regular. 

22d.  Relapse  to  stupid  condition  ;  passed  urine  in  bed  ;  became  choked 
while  eating  some  beef  at  dinner. 

23d.  Seems  to  take  no  interest  in  anything  that  is  said  to  her. 

24th.  Two  furuncles  (one  surrounded  by  a  red  areola)  have  appeared 
on  the  right  buttock. 

25th.  Still  absolute  loss  of  power  and  sensation  on  right  side,  and  con- 
tinued drowsiness. 

2ftth.  Involuntary  discharges  of  feces  and  urine. 

27th.  She  brightens  up  after  receiving  nourishment,  but  cries  and  seems 
distressed. 

2Qth,  2  P.  M.  Nurse  called  the  house  physician,  seeing  that  she  appeared 
to  have  stopped  breathing.  Her  eyes  were  turned  upwards  and  her  lips 
blue,  and  her  pulse  was  very  weak  and  feeble.  Ordered  stimulants. 

Nov.  1.  Made  no  attempt  to  speak,  but  answered  "yes"  or  "  no"  cor- 
rectly to  any  questions  asked. 

2d.  Feverish  and  restless;  temperature  101°;  discharges  from  the 
bowels  have  stopped. 

6th.  Complains,  of  pain  in  her  thigh  and  legs  ;  cries  a  great  deal ;  refuses 
food,  and  appears  to  be  very  much  run  down. 

8th.  Right  pupil  approaching  more  nearly  the  size  of  the  left ;  appetite 
still  good  ;  bowels  regular.  Cannot  write  her  name  with  the  left  hand,  but 
makes  a  disorderly  scrawl.  Asked  her  to  repeat  several  words;  pro 


132  OCCLUSION    OF    INTRACRANIAL    VESSELS. 

nounced  "  eggs"  very  distinctly  ;  for  "  cross,"  she  said  "  cork."     7  P.  M. 
Quite  feverish  and  restless  ;  temperature  102°. 

13th.  Has  still  fever;  temperature  102°.  Ordered  quinine  and  cold 
sponging.  She  cries,  and  appears  very  sensitive  when  moved. 

14th.  Slept  well  last  night.  7P.M.  Temperature  100°.  Several  inguinal 
glands  on  the  right  side  are  somewhat  enlarged  and  painful  on  pressure. 

2'2d.  Complains  of  great  pain  at  the  attachment  of  the  adductors  to 
femur. 

The  month  of  December  was  passed  without  anything  occurring  of  spe- 
cial note.  The  patient  grew  much  more  feeble ;  there  was  no  improve- 
ment in  the  paralysis,  and  she  became  reduced  to  a  shadow.  The  tem- 
perature continued  elevated,  and  she  was  restless  and  delirious  at  times. 
Of  course  the  burden  of  her  delirium  consisted  of  two  or  three  words, 
which  were  repeated  over  and  over. 

Jan.  8,  1877.  Dr.  Naylor  was  called  to  see  the  patient  at  4  o'clock  P. 
M.  He  then  noticed  some  fibrillary  contraction  about  the  right  angle  of 
the  mouth,  with  an  occasional  spasm  of  the  upper  lip,  when  it  would  be 
drawn  up  with  the  wing  of  the  nostril.  Eyes  closed,  pupils  more  con 
tracted  than  usual,  face  Hushed  and  head  hot ;  temperature  in  axilla  101^°. 
When  left  foot  was  pricked  she  turned  it  up ;  pulse  too  rapid  to  count ; 
heart's  action  tumultuous.  Tr.  digitalis,  gtts.  xv.  5  o'clock  P.  M. 
Spasm  of  lip  still  continues  ;  lies  on  her  back  with  eyes  closed,  and  gives 
no  evidence  of  pain  when  any  part  of  the  body  is  pricked  ;  pulse  in  same 
state.  6  o'clock  P.  M.  Breathing  heavily  ;  eyelids  closed  and  eyes  turned 
upward ;  pupils  do  not  contract  to  light,  but  lids  contract  slightly  when 
conjunctiva  is  touched;  reflex  irritability  very  much  impaired;  pulse  100; 
temperature  102°.  7  o'clock  P.  M.  Spasm  of  mouth  has  ceased  ;  respi- 
ration very  slow  and  feeble  ;  pulse  80 ;  temperature  102°.  lOo'clock  P.  M. 
Mucous  rales  heard  over  whole  chest.  12  o'clock  A.  M.  Patient  remains 
unconscious.  2  o'clock  A.  M.  Patient  still  breathes  slowly  and  feebly ; 
small  amount  of  frothy  mucus  comes  out  of  her  mouth  ;  patient  remained 
in  this  condition  until  death,  10  A.  M.,  9th  instant. 

Autopsy — Head :  dura  mater  normal ;  sinuses  empty  ;  moderate  effu- 
sion into  arachnoid  cavity  ;  pia  mater  intensely  congested ;  left  middle 
cerebral  artery  about  ^  incli  from  its  origin  occupied  by  a  firm  thrombus ; 
beyond  this  the  artery  was  thin,  ribbon-like,  scarcely  perceptible,  and 
finally  lost ;  membranes  readily  detached  from  the  brain,  leaving  the 
sulci  gaping  widely  over  the  under  surface  of  anterior  lobe,  left  side 
about  third  frontal  convolution  and  island  of  Reil.  In  detaching  the  mem- 
branes portions  of  brain-substance  were  removed  with  them,  leaving  an 
almost  pultaceous  mass  exposed;  indeed  the  whole  of  under  surface  of  an- 
terior lobe  was  much  softened,  but  this  was  most  marked  near  the  lateral 
border  ;  under  surface  of  middle  lobe  slightly  softened  ;  superior  and  lateral 
aspect  of  anterior  and  middle  lobes  from  fissure  of  Rolando  forwards  was 
in  a  very  softened  condition,  breaking  down  under  the  least  pressure,  of  a 
pale  yellowish-gray  color,  in  marked  contrast  with  other  parts  of  the  brain, 
which  on  section  showed  very  numerous  puncta  vasculosa,  and  were  of  the 
normal  color.  Thalamus  opticus  somewhat  softer  than  that  of  the  right 
side  ;  corpus  striatum  much  softened  and  of  a  yellowish  color.  Thorax : 
lungs  oedematous,  and  poured  out  an  abundance  of  mucus  on  section.  Heart : 
insufficiency  of  mitral  valve ;  no  vegetations  noticed ;  left  ventricle  entirely 
filled  by  a  firm  white  clot  entangled  in  chordae  tendinse  and  projecting 
into  aorta ;  abdomen,  kidneys,  liver,  and  spleen  much  congested. 


THROMBOSIS    OF    CEREBRAL    ARTERIES.  133 

Causes — Men  are  more  often  subject  to  arterial  thrombosis  than 
women  or  children,  though  we  find  the  great  number  of  cases  of  thrombosis 
of  the  sinuses  to  be  among  women,  and  this  is  perhaps  due  to  the  tendency 
of  this  sex  to  chlorosis. 

Gintrac  considers  very  young  children  to  be  subject  to  venous  throm- 
bosis. Of  37  cases  seen  by  him,  14  were  among  infants ;  but  arterial  throm- 
bosis is  a  condition  peculiar  to  advanced  life,  and  instances  before  middle 
age  are  not  at  all  common  unless  they  be  of  a  specific  nature.  The  ex- 
citing causes  are  numerous,  but  it  may  be  assumed  in  nearly  every  instance 
that  the  blood  is  in  a  state  of  hyperinosis  as  a  consequence  of  acute  disease, 
such  as  rheumatism  or  pneumonia.  Excessive  heat  is  very  often  a  cause. 
Dickinson1  gives  four  cases,  in  two  of  which  heat  was  the  cause,  in  one 
other  intemperance,  and  in  the  fourth  violent  vomiting. 

In  many  of  these  patients  there  is  old  heart  disease  with  some  enfeebled 
action  of  that  organ.  The  basilar  artery,  which  receives  its  blood  from 
the  vertebral  arteries,  may  be  the  seat  of  a  clot  at  its  remote  end  when 
heart  force  is  preternaturally  weak,  but  this  is  a  rare  form  of  the  disease. 
I  have  already  spoken  of  peripheral  phlegmatous  troubles,  and  it  is  only 
necessary  to  call  attention  to  the  danger  which  may  arise  from  carbuncle. 
The  puerperal  state  favors  the  formation  of  thrombi,  and  just  as  phleg- 
masia  alba  dolens  is  brought  about,  so  may  the  thrombosis  of  the  cerebral 
arteries  be  produced.  The  graver  variety  of  intracranial  thrombosis  may 
be  produced  by  internal  or  external  cause.  Lancereaux  collected  39  cases, 
30  of  which  were  connected  with  caries  of  some  of  the  cranial  bones,  and 
24  with  otitis.  In  one-half  of  these  cases  there  were  multiple  abscesses  of 
the  brain. 

In  conclusion  I  would  allude  to  the  possibility  of  traumatic  origin,  a 
variety  of  blood-states,  and  pressure  from  intracranial  tumors,  exostoses, 
and  thickened  meninges. 

Morbid  Anatomy  and  Pathology — Von  Dusch,  Parnum,2 
Grissole,3  Zahn,  and  a  host  of  observers  have  devoted  themselves  to  the 
study  of  this  subject,  and  since  the  original  observations  of  Kirkes4  were 
published  in  1852,  which  were  devoted  to  the  pathology  of  thrombosis  as 
well  as  embolism,  a  great  deal  has  been  written.  Parnum  and  Burro wes5 

'  O 

both  experimented  by  injecting  substances  into  the  circulation,  and  Bur- 
rowes  probably  relates  the  earliest  case  of  recognized  thrombosis. 

Zahn  gives  the  following  concise  description  of  the  pathological  process 
which  attends  the  production  of  a  thrombus.  "  The  intensity  and  the  dura- 
tion of  the  injury,  together  with  the  previous  condition  of  the  individual, 
determine  the  durability  of  the  clot.  The  process  of  formation  is  the  fol- 
lowing. Colorless  blood-corpuscles  adhere  to  a  part  of  the  intima  denuded 

1  Loc.  cit. 

2  Virchow's  Archiv,  xxv.  3-6,  pp.  308-338,  433,  530,  1862. 

3  Pathol.  Intern.,  p.  247.  4  Med.  Chir.  Trans,  1852. 
5  Med.  Gaz.,  vol.  xvi.  1834-5. 


134  OCCLUSION    OF    INTRACRANIAL    VESSELS. 

by  an  injury  of  its  endothelium.  They  accumulate  there,  form  a  ring- 
like  obstruction,  and  gradually  the  clot  obstructs  the  vessel  altogether.  It' 
the  injury  be  slight,  and  the  nutrition  of  the  individual  unimpaired,  the 
current  of  blood  soon  breaks  through  the  blood-clot  and  carries  along  the 
flakes  of  the  colorless  blood-corpuscles.  The  normal  condition  is  soon 
restored.  If  the  injury  of  the  vessel  be  more  severe,  and  the  surrounding 
tissue  already  in  a  state  of  irritation,  the  thrombus,  whilst  forming  in  the 
same  way  as  described,  is  firmer  and  larger.  The  obstruction  is  more 
complete,  and  lasts  for  twenty-four  hours  and  more  ;  after  that  period  the 
thrombus  begins  to  disintegrate  into  granular  fibrine,  the  outlines  of  the 
blood-corpuscles  composing  the  thrombus  cease  to  be  visible,  and  thus  an 
uninterrupted  circulation  is  re-established."1  In  more  serious  trouble  the 
detached  clots  may  be  the  nuclei  of  larger  ones  in  the  sinuses  if  the  con- 
dition of  the  arterial  walls  be  such  as  to  favor  more  extended  formation  of 
thrombi  so  that  the  vessels  become  entirely  occluded. 

The  consequence  of  arterial  occlusion  is  the  formation  of  an  extended 
clot  which  blocks  up  the  vessel  more  fully,  and  consequent  ischaemia  of 
distal  parts.  Through  the  agency  of  outside  vessels  collateral  circulation 
is  generally  established  in  a  short  space  of  time.  If,  however,  the  anato- 
mical site  be  such  as  to  interfere  with  this  provision  of  nature,  softening 
or  tardy  degeneration  will  ensue.  This  softening,  when  it  follows,  is  ex- 
pressed by  a  series  of  changes,  which  occur  about  as  follows  :  Red  soft- 
ening in  from  24  to  48  hours,  while  the  yellow  change  does  not  take  place 
until  after  14  days.  But  of  this  condition  of  affairs  I  will  speak  in  a  sub- 
sequent chapter.  The  carotid  arteries  and  their  termination  are  more 
often  affected,  and  basilar  vertebrals,  anterior  cerebral,  and  posterior  com- 
municating come  next,  in  the  order  I  have  given  them.  The  pathological 
processes  in  the  second  form  of  intracranial  thrombosis,  viz.,  that  affect- 
ing the  sinuses  and  veins,  are  much  more  gross.  Either  through  sluggish 
circulation  of  the  blood  on  the  part  of  a  weak  heart,  pressure  upon  a  sinus, 
or  unusual  density  of  the  blood,  coagulation  occurs,  the  arterial  flow  is  in- 
terfered with,  a  part  of  the  brain  is  deprived  of  blood,  and  serum  is  effused. 
If  the  disease  be  due  to  outside  causes,  there  may  be  an  extension  of  in- 
flammatory action  from  without  in  the  manner  I  have  described.  By  an 
extension  of  thrombosis,  a  form  of  meningitis  resembling  tubercular  men- 
ingitis may  be  produced.  Several  of  these  cases  have  been  seen  by  Scuch." 
An  artery  which  is  the  seat  of  a  thrombus  presents  these  appearances : 
The  inner  coat  is  rough  and  perhaps  corrugated ;  the  artery  as  a  whole 
may  be  hard  and  discolored,  with  diminution  in  calibre  and  a  deposition 
of  recent  or  ancient  date,  in  which  latter  case  it  will  be  pale  and  tough, 
while  atheroma  is  not  uncommonly  present.  Fox*  has  observed  that  the 
part  of  the  clot  adherent  to  the  inner  coat  of  the  vessel  is  much  more  dense 
than  that  nearest  the  centre.  When  the  capillaries  are  implicated,  they 

1  Virchow's  Archiv,  Band  Ixii.,  Heft  1,  Nov.  1874. 

2  Verhandlung  dur  Wurz.,  p.  Mod.  Geselschaft,  viii.  179. 
8  Path.  Anat.  of  the  Nervous  Centres,  p.  32. 


THROMBOSIS    OF    SINUSES    AND    VEINS.  135 

are  generally  found  to  be  hard  and  calcareous.  In  thrombosis  of  the  large 
sinuses  or  veins,  the  morbid  appearances  are  much  more  striking.  The 
thrombi  are  large,  and,  if  old,  of  a  gray  color,  and  it  is  not  rare  to  find 
pus,  effusions  of  serum  into  neighboring  parts,  and  perhaps  some  menin- 
gitis. Von  Dusch  has  collected  57  cases,  which  are  given  by  Fox.1  In 
32  the  thrombosis  resulted  from  gangrenous,  erysipelatous,  and  other  in- 
flammations of  the  body  (chiefly  of  head).  In  4  foreign  bodies  were 
found.  In  15  it  appears  to  have  resulted  from  asthenic  circulation.  In 
G  cases  nothing  positive  could  be  ascertained. 

Diagnosis — There  are  very  few  conditions  with  which  that  under 
consideration  may  be  confounded.  When  we  remember  that  in  throm- 
bosis the  development  of  symptoms  is  gradual,  the  loss  of  speech  incom- 
plete, and  primary ;  and  in  cerebral  hemorrhage  the  onset  is  sudden,  the 
aphasia  is  secondary  to  a  loss  of  consciousness,  and  the  paralysis  more 
marked,  the  diagnosis  from  this  disease  is  not  so  difficult.  Doubts  may 
arise  in  our  minds  when  we  are  to  decide  whether  or  not  the  case  before 
us  is  one  of  thrombosis  or  uncomplicated  softening.  Thrombosis  is  rarely 
attended  by  marked  elevation  of  temperature,  while  the  opposite  is  to  be 
observed  in  cerebritis,  which  presents  as  symptoms  trembling  and  per- 
haps muscular  rigidity.  The  psychical  symptoms  are  also  more  strongly 
marked.  The  more  serious  form  can  be  diagnosed  by  the  coexistence  of 
other  conditions  which  may  favor  its  origin. 

Treatment — The  chief  indication  seems  to  be :  The  improvement 
of  the  condition  which  influenced  the  production  of  the  thrombus.  If 
arterial  tension  be  at  all  weak,  we  may  combine  digitalis  and  iron  (F.  21), 
give  tonics  (FF.  40,  43,  8,  9,  10,  32),  and  improve  the  patient's  general 
condition  by  good  food  and  stimulants.  Nature  will  arrange  the  process 
of  collateral  blood-supply,  and  we  may  aid  her  by  enforcing  rest  and  quiet. 


THROMBOSIS  OF  SINUSES  AND  VEINS. 

When  a  large  sinus  or  vein  is  involved,  the  resulting  symptoms  are 
much  more  complex  and  difficult  to  diagnose. 

Lancereaux,2  who  has  written  quite  extensively  about  this  form  of  dis- 
ease, has  divided  it  into  two  grades,  in  regard  to  the  variety  of  morbid 
action.  One  of  these  is  inflammatory,  the  other  is  non-inflammatory. 
The  first  form  is  dependent  upon  the  extension  of  some  inflammatory  pro- 
cess, usually  from  the  ear,  while  the  other  is  attended  by  coagulation  of 
the  blood  in  sluggish  circulation. 

'Von  Dusch3  does  not  agree  with  him,  but  Tonnele,  quoted  by  Grisolle,4 
makes  the  same  varieties  as  Lancereaux. 


1  Loo.  fit.,  p.  35. 

2  Lancereaux,  De  la  Thrombose,  etc.,  Paris,  1862. 

3  Zeits.  fur  Ration.  Med.,  B.  vii.,  1859,  p.  11. 

4  Op.  cit.,  tome  ii.  p.  240. 


136  OCCLUSION    OF    INTRACRANIAL    VESSELS. 

The  seats  of  this  pathological  condition  are  the  longitudinal,  lateral, 
basal  sinuses,  and  the  large  veins  communicating  therewith.  Bastian* 
alludes  particularly  to  the  longitudinal  sinus  as  the  most  common  seat,  and 
describes  the  tendency  to  plugging  up  of  the  cerebral  veins  on  both  sides. 

As  I  have  said,  the  symptoms  are  very  obscure,  but  in  every  case  we 
may  consider  them  to  be  the  indication  of  pressure.  Headache,  delirium, 
coma,  convulsions,  ocular  troubles,  and  generally  death  in  a  very  short 
space  of  time  mark  the  course  of  the  disease.  Mr.  Tuckwell8  reports  a 
case  which  is  a  representative  of  the  anaemic  form.  It  is  as  follows  : — 

Eliza  C.,  «et.  16,  was  admitted  to  Radcliffe  Infirmary  on  the  20th  day 
of  April,  1871.  She  ceased  working  a  month  before  on  account  of  palpi- 
tations, shortness  of  breath,  weakness,  irregularity  of  the  menses,  etc. 
Two  weeks  before  admission  she  began  to  suffer  from  violent  headache. 
She  never  had  fits.  A  condition  of  decided  chlorosis  was  diaj:nos< •<!. 
There  was  a  systolic  murmur  at  base  and  venous  murmur  in  the  neck ; 
nothing  else  abnormal  was  detected.  She  was  put  to  bed. 

April  21.  She  sat  up,  but  it  was  noticed  that  she  lolled  about  in  a 
strange  manner,  and  seemed  stupid.  Her  right  hand  and  arm  were  weak, 
and  she  could  not  raise  them  to  shake  hands.  Headache  still  severe. 

24th.  Remained  in  same  apathetic  state ;  the  paralysis  of  arm  had 
increased,  and  she  could  not  move  fingers  or  hand  at  all;  headache.  She 
became  comatose,  and  died  after  the  visit  of  Dr.  Tuckwell  and  his  col- 
league, Dr.  Palmer. 

Autopsy  twenty-four  hours  after  death.  On  removing  skullcap,  the 
dura  mater  covering  right  hemisphere  was  found  to  be  of  a  dark  color, 
and  the  longitudinal  sinus,  when  examined,  was  found  half  way  blocked  up 
by  a  firm  white  blood-clot  of  some  age.  Cerebral  veins  on  the  surface  of 
the  middle  and  posterior  part  of  right  hemisphere  were  all  occluded  by 
dark  clots.  On  removing  the  brain,  blood  was  found  effused  in  the  right 
middle  cerebral  fossa,  extending  down  into  the  spinal  canal. 

Lateral  and  basal  sinuses  were  filled  with  clots  of  some  age.  The  pons 
and  medulla  were  covered  by  a  clot  of  recent  date.  General  softening  of 
the  brain  was  observable,  the  optic  thalami  and  corpora  striata  being  par- 
ticularly affected.  The  arteries  were  all  healthy,  as  well  as  the  bone 
about  the  sinuses. 

Another  case  is  reported  by  Dr.  Tuckwell,  which  presented  symptoms 
which  were  very  much  like  those  of  his  own  case. 

Von  Dusch8  has  spoken  of  epistaxis  with  thrombosis  of  the  longitudinal 
sinus  as  a  common  symptom,  and  Meissner  has  called  attention  to  grind- 
ing of  the  teeth,  profuse  diarrhoea,  and  exhaustion,  together  with  certain 
changes  in  the  configuration  of  the  head.  In  children  he  has  found  de- 
pressed fontanelles,  lapping  of  cranial  bones,  and  unequal  distension  of 
the  jugular  veins.  Metastatic  abscesses,  indicated  by  local  symptoms, 
have  been  found  by  many  observers.  Lancereaux  estimates  that  nearly 
half  of  all  the  cases  are  thus  complicated.  I  have  seen  one  case  where 

1  Bastian,  Common  Forms  of  Paralysis,  etc.,  p.  22. 

8  St.  Bartholomew's  Hospital  Reports,  vol.  x.,  1874,  p.  35. 

3  Loc.  cit. 


EMBOLISM    OP    THE    CEREBRAL    VESSELS.  137 

erysipelas  was  undoubtedly  the  cause  of  the  cerebral  thrombosis,  and  after 
death  the  great  sinuses  were  found  to  be  filled  with  semi-purulent  matter, 
and  there  were  abscesses  in  the  liver  and  other  parts  of  the  body.  These 
eases  are  not  so  exceptional  as  they  are  generally  supposed  to  be,  but 
diagnosis  before  death  is  rarely  made. 

An  autopsy  made  at  the  New  York  Hospital  by  Dr.  Ammidown,  who 
kindly  invited  me  to  be  present,  revealed  the  following  beautiful  evidences 
of  thrombosis  of  the  cerebral  sinuses  which  followed  septicaemia  : — 

The  boy  had  died  after  several  days'  illness,  the  original  injury  being  a 
compound  fracture  of  the  bones  of  the  left  leg.  The  autopsy  was  held  on 
September  loth,  the  day  of  his  death. 

The  liver,  kidneys,  and  lungs  showed  evidences  of  acute  congestion, 
and  the  heart  contained  two  ante-mortem  clots ;  one  accupying  the  right 
auricle,  and  the  other  the  right  ventricle.  The  lungs  were  carefully  ex- 
amined, and  a  pyramidal  infarction  was  found  at  the  border  of  the  inferior 
lobe  of  the  left  lung.  The  head  was  open,  and  the  dura  mater  was  found 
to  be  quite  healthy,  except  in  the  superior  longitudinal  sinus,  which  was 
almost  completely  filled  with  a  well-organized  thrombus  of  a  pale  color. 
One  of  the  large  descending  veins  in  the  parietal  region  was  occluded,  and 
when  the  dura  mater  was  removed,  a  large  pouch,  filled  with  limpid  and 
perfectly  clear  serum,  was  found  beneath,  which  pressed  upon  the  parietal 
convolutions  just  posterior  to  the  fissure  of  Rolando.  This  was  beneath 
the  arachnoid.  At  no  other  point  was  there  any  abnormal  collection  of 
fluid,  and  in  no  place  was  there  any  evidence  of  structural  changes  of  the 
brain-substance  proper.  The  lateral  sinuses  were  partially  filled  with 
thrombi,  and  contained  some  very  fluid  blood.  The  left  petrosal  vein 
\va>  empty,  as  were  others  which  were  higher  up.  No  arterial  occlusion 
was  found.  The  patient  had  died  suddenly  in  convulsions  with  coma. 

Causes Blows  upon  the  head,  injuries  of  various  kinds,  extension  of 

otitis,  intemperance,  and  the  causes  I  have  already  enumerated,  may  be 
mentioned.  There  seems  to  be  no  special  dependence  upon  age  or  sex, 
though  it  may  be  said  that  most  of  the  cases  occur  during  adult  life. 

What  I  have  already  said,  and  the  excellent  cases  of  Tuckwell,  which 
have  been  presented,  render  it  unnecessary  to  say  more  about  the  morbid 
anatomy,  pathology,  or  diagnosis. 

In  regard  to  the  prognosis,  there  can  be  no  question.  It  is  about  as 
bad  as  it  can  well  be.  As  to  treatment,  the  most  we  can  do  is  to  build  up 
our  patient,  and  reduce  the  danger  of  external  disease  by  favoring  a  free 
escape  of  pus  if  the  original  disease  be  otitis,  and  there  be  an  accumulation. 
We  may  employ  local  cold  and  derivatives,  but  even  these  do  little  good 
after  the  disease  is  recognized. 


EMBOLISM  OF  THE  CEREBRAL  VESSELS. 

The  cerebral  arteries  and  capillaries  are  alike  subject  to  this  form  of 
mechanical  obstruction,  but  the  former  are  perhaps  the  most  common  seat 


138  OCCLUSION    OF    INTRACRANIAL    VESSELS. 

of  the  lodgment  of  fibrinous  plugs.  The  little  bodies  which  are  forced  into 
the  vessels  are  always  from  some  other  part  of  the  system,  and  are  not 
formed  in  the  vessel,  as  is  the  case  in  thrombosis. 

Embolism  also  differs  from  thrombosis  in  the  fact  that  the  latter  is 
slowly  developed,  and  attended  by  gradual  narrowing  of  the  vessel ;  while 
the  condition  under  consideration  is  a  sudden  accident,  and  may  occur  in 
a  perfectly  healthy  vessel:  the  converse  is  the  rule  in  thrombosis. 

Symptoms. — .Unless  there  is  previous  acute  endocarditis,  there  will 
seldom  be  any  warning,  the  patient  being  suddenly  stricken  down  as  the 
little  plug  is  violently  forced  into  some  vessel  of  the  brain.  There  may 
even  be  no  loss  of  consciousness,  though  this  is  the  exception.  Uncon- 
sciousness invariably  occurs  when  a  large  embolon  plugs  up  some  such 
artery  as  the  middle  cerebral ;  but  if  the  embolon  be  small,  and  the  artery 
occluded  is  one  concerned  to  a  very  limited  extent  in  the  vascular  supply 
of  the  cerebrum,  the  unconsciousness  may  be  but  transitory,  and  psychical 
symptoms  of  slight  moment  will  constitute  the  sole  indications  of  confused 
mental  activity. 

The  eyes  are  sensitive  to  light,  the  pulse  is  small  and  rapid,  and  there 
is  usually  pallor.  There  are  no  indications  of  pressure,  no  stertor,  no 
tumultuous  respiration,  nor  full  pulse,  and  the  pupils  are  either  dilated  or 
irregularly  contracted. 

If  the  heart  be  auscultated,  various  murmurs  or  friction-sounds  will  in 
many  cases  be  heard.  Mitral  murmurs  are  perhaps  the  most  common. 

Paralysis  taking  the  form  of  complete  or  incomplete  hemiplegia  is  the 
result  of  such  sudden  arterial  occlusion. 

Special  facial  muscles  may  be  those  affected,  or  various  modifications  of 
sensation,  such  as  anaesthesia  or  hyperaesthesia,  may  be  detected,  but  rigidity 
or  contractures  are  rarely  present  unless  there  is  secondary  disorganiza- 
tion, and  they  are  never  seen  during  the  early  stages.  Vertigo  is  a  dis- 
agreeable and  common  symptom,  and  is  sometimes  attended  by  cerebral 
vomiting.  Of  course  aphasia  is  an  almost  invariable  consequence  of  em- 
bolism, as  the  middle  cerebral  artery  is  so  commonly  occluded.  This 
aphasia  is  of  variable  extent,  and  is  ataxic  or  amnesic,  but  generally  the 
latter.  On  the  other  hand,  the  patient  may  be  simply  stupid  and  taciturn, 
refusing  to  answer,  or  he  may  be  troubled  with  a  light  form  of  clumsiness 
or  slowness  of  speech.  The  headache,  which  is  subsequent  to  the  loss  of 
consciousness,  is  coincident  ordinarily  with  the  re-establishment  of  col- 
lateral circulation,  and  if  further  changes  occur  there  may  be  intense  head- 
pain,  delirium,  mania,  or  symptoms  indicative  of  softening.  The  duration 
of  this  stage  varies  greatly.  I  have  seen  examples  where  the  symptoms 
were  trifling  and  transitory,  such  as  headache,  awkward  speech,  and 
paralysis  of  one  arm  rapidly  disappearing.  Other  cases  are  correspondingly 
serious.  Mr.  Shaw1  reports  a  case  which  proved  fatal  in  twenty-four  hours, 
and  others  have  detailed  examples  in  which  death  ensued  in  from  thirty- 
six  to  forty-eight  hours. 

1  Trans,  of  Path.  Soc.  of  London,  vol.  iv. 


EMBOLISM    OF    THE    CEREBRAL    VESSELS.  139 

It  is  very  common  to  find,  at  the  same  time,  symptoms  indicative  of 
embolism  of  other  organs.  The  spleen,  lungs,  and  organs  which  receive 
a  large  supply  of  blood,  or  are  in  the  direct  line  of  arterial  supply,  are  apt 
to  be  involved  as  well  as  the  brain.  It  rarely  happens  that  two  or  more 
cerebral  arteries  are  simultaneously  plugged.  In  such  cases  the  symptoms 
are  complicated.  One  case  is  recorded  in  which  both  middle  cerebral 
arteries  were  occluded,  and  the  following  case  reported  by  Sokolowski1  is 
an  example  of  coexisting  splenic  and  cerebral  embolism  : — 

The  patient  was  a  servant,  married,  aged  23,  who  had  always  menstru- 
ated regularly,  except  when  she  was  pregnant  second  year  before,  and 
then  gave  birth  to  a  healthy  child.  Her  health  had  been  ordinarily  good. 
Four  days  before  her  admittance  to  the  hospital  she  had  suffered  from 
alternate  chills  and  heat,  with  headache  and  constipation.  On  admis- 
sion her  pulse  was  100 ;  temperature,  102.6°.  Heart  friction  sound 
at  apex,  but  nowhere  else.  Passed  53  oz.  urine  in  24  hours ;  sp.  gr. 
1025. 

October  13th.  She  suddenly  became  paralyzed  on  the  right  side,  lost  all 
power  of  speech,  and  only  moaned  and  cried  in  a  frightened  manner.  The 
third  day  after,  acute  idiopathic  endocarditis  was  diagnosed.  The  right 
ventricle  was  found  to  be  greatly  enlarged.  Temp.  101.2°  ;  pulse,  100. 
After  paralysis  she  lost  hearing  in  the  right  ear ;  pupils  were  normal ;  left 
side  of  mouth  was  drawn  up.  Anaesthesia  of  paralyzed  parts.  Urine  and 
feces  passed  unconsciously.  Spleen  tender  and  enlarged.  An  additional 
diagnosis  was  now  made.  Embolism  of  left  middle  cerebral  artery,  and 
embolism  of  splenic  artery.  The  loss  of  speech  was  peculiar.  She  was 
unable  to  articulate  at  all,  though  there  was  sufficient  evidence  of  mental 
activity  and  originating  power,  so  she  communicated  with  her  friends  by 
signs.  The  paralysis  had  begun  to  disappear  in  the  right  leg  below  the 
knee,  and  she  could  move  her  foot  slightly.  The  temperature  on  the  first 
day  was  102.2°  ;  pulse,  90.  In  the  evening,  104.8°  ;  pulse,  100.  On  the 
second  day,  Oct.  14,  there  was  much  improvement.  The  morning  tem- 
perature was  102.8°,  and  the  evening  103.8°. 

loth.  All  paralysis  and  alalia  have  vanished.  She  is,  however,  ex- 
tremely weak.  During  the  next  two  or  three  days  a  diarrhoea,  loss  of 
appetite,  and  considerable  increase  of  tenderness  over  the  spleen  appeared. 

28^.  35  oz.  of  urine  were  passed,  which  contained  albumen,  hyaline 
casts,  and  urates  in  abundance. 

November  Wth.  She  has  grown  gradually  worse,  is  no  longer  able  to 
answer  questions,  but  repeats  words  and  sentences  over  and  over.  There 
is  marked  loss  of  memory.  The  fever  has  greatly  increased,  the  evening 
temperature  being  105.2°  ;  pulse  120,  and  quite  thready.  There  are  evi- 
dences of  bronchitis  and  pulmonary  difficulty.  Urine  greatly  decreased  in 
quantity,  and  albumen  increased  ;  tongue  quite  dry. 

'20th.  She  died.  There  was  extensive  hypostatic  pneumonia;  con- 
sciousness remained  to  end. 

Autopsy Arteries  at  base  healthy,  except  middle  cerebral  on  left 

This  contained  a  semi-transparent  embolism  of  cartilaginous  consistency. 
Right  side  of  brain  healthy,  though  pale.  The  left  side  in  the  same  con- 
dition, except  at  the  island  of  Reil,  and  gray  matter  of  lenticular  nucleus, 


Deutsche  Med.  Woch.,  Dec.  15,  1875. 


140  OCCLUSION    OF    INTBACRANIAL    VESSELS. 

which  were  small,  hard,  and  yellow,  and  showed  evidences  of  softening 
and  subsequent  cicatrization.  The  heart  was  enlarged,  and  yellow  spots 
were  found  beneath  the  endocardium.  The  edges  of  the  mitral  valves  were 
thickened  and  covered  with  coagula.  The  spleen  enlarged,  "  blocked," 
and  the  splenic  artery  occluded. 

Cases  have  been  reported  where  embolism  followed,  or  was  connected 
with,  chorea,  and  this  connection  has  been  made  use  of  in  the  explanation 
of  the  pathology  of  the  latter  disease.  One  of  these  cases,  seen  by  Murchi- 
son,1  is  worthy  of  mention. 

The  patient,  a  boy  14  years  old,  had  suffered  from  chorea  when  seven 
years  old,  from  which  he  recovered.  Two  weeks  before  h<-  died,  irregular 
choreic  movements  appeared,  connected  with  a  bellows  murmur  at  the 
left  apex.  When  seen,  June  12th,  the  pulse  was  120  ;  temperature.  102°. 
There  was  a  pericardial  friction  sound,  but  no  pain  in  joints  or  other 
symptoms  of  rheumatism  or  endocarditis. 

June  28.  Sudden  unconsciousness,  head  drawn  to  right  side,  extreme 
rigidity,  twitching  on  right  side.  Pulse,  145.  Pupils  normal  and  equal, 
but  subsequently  contracted  ;  no  paralysis.  Died  June  29.  Vegetations 
on  mitral  valves,  spleen  containing  emboli.  Left  vertebral  and  left  in- 
ternal carotid  arteries  blocked  by  pale,  firm,  and  easily  detached  coagula; 
left  hemisphere  considerably  softened.  Examination  revealed  no  small 
embolf  in  capillaries. 

A  case  of  my  own,  showing  an  accident  which  may  occur  in  the  course 
of  certain  acute  diseases,  seems  to  me  to  be  of  sufficient  interest  to  present, 
as  it  may  call  attention  to  a  cause  of  death  which  is  probably  sometimes 
overlooked. 

Mr.  N.,  set.  35,  a  stout,  full-blooded  man  of  good  habits  and  no  vices, 
took  to  his  bed  on  the  25th  of  June,  1874. 

He  had  contracted  a  "  bad  cold"  at  the  theatre,  and  the  next  day  was 
seized  with  pain  in  the  left  side,  was  chilly  and  uncomfortable,  and  when 
I  saw  him  on  the  evening  of  the  same  day,  he  had  a  violent  headache. 
His  skin  was  hot,  and  his  pulse  hard  and  rapid.  The  thermometer  indi- 
cated a  temperature  of  101°  ;  pulse,  122.  At  the  base  of  the  left  lung 
crepitant  rales  were  heard.  Flaxseed  poultices  were  applied,  and  quinine 
and  other  remedies  administered.  For  the  next  four  or  five  days  the 
lungs  underwent  consolidation,  and  nearly  all  of  the  physical  signs  con- 
nected with  the  different  stages  of  pneumonia  were  observed.  The  most 
marked  of  these  was  a  high  temj>erature,  which  ranged  between  103°  and 
105°  for  six  days.  Resolution  was  slow,  and  but  a  few  sputa  were  brought 
up,  but  the  temjx'rature  had  fallen  to  some  extent.  I  was  sent  for  in  haste 
on  the  evening  of  the  fourteenth  day,  an  hour  after  my  ordinary  visit,  to 
find  that  the  patient  had  suddenly,  while  taking  his  beef-tea,  fallen  back 
unconscious,  and  had  remained  so  ever  since.  This  was  about  half  an  hour 
before  my  being  sent  for. 

His  pupils  were  widely  dilated,  and  his  corneae  when  touched  were  sen- 
sitive ;  his  legs  and  arms  were  extended.  His  temperature  was  not  high, 
and  his  breathing  had  not  changed  very  much  from  what  it  was  when  I 
saw  him  earlier  in  the  day. 

1  London  Path.  Soc.  Trans.,  vol.  xxii. 


EMBOLISM    OF    THE    CEREBRAL    VESSELS.  141 

After  an  hour  and  a  half  he  made  some  movements  which  showed  slight 
voluntary  control,  and  vomited,  turning  his  head  slightly  to  do  so.  He 
uttered  no  sounds  except  low  moans.  Towards  morning  his  breathing  be- 
came more  troubled,  and  he  rolled  in  the  bed. 

At  about  nine  o'clock  in  the  morning  of  the  next  day  he  seemed  to 
recognize  those  about  him,  and  made  signs  which  were  not  understood, 
when  he  knit  his  brows  and  seemed  perplexed.  He  refused  food,  but 
permitted  an  enema  of  beef-tea  to  be  injected,  but  this  was  not  retained. 
It  was  then  found  that  he  was  hemiplegic  on  the  right  side.  Later  in 
the  day  he  passed  his  urine  in  bed. 

16th  day.  Did  not  sleep  last  night.  The  temperature  104°;  pulse, 
130,  full  and  hard.  After  my  visit  this  morning  he  became  comatose. 
3  P.  M.,  died. 

Autopsy  20  hours  after  death — Lungs :  right,  rather  more  pinkish 
than  normal ;  some  spots  of  induration  at  base.  Left,  solidified  through- 
out most  of  its  substance  ;  when  cut,  bloody  serum  exuded.  Heart  some- 
what enlarged.  Mitral  valves  were  covered  by  stringy  clots.  The  right 
ventricle  contained  a  large  fresh  clot.  Kidneys :  right,  normal ;  left, 
somewhat  smaller  than  it  should  be ;  contained  a  small  cyst  beneath  the 
capsule.  Head :  On  opening  the  cranial  cavity,  the  vessels  of  the  dura 
mater  were  filled  with  dark  blood.  The  longitudinal  sinus  contained  a 
quantity  of  thick,  clotted  blood,  which  was  almost  black.  The  left  hemi- 
sphere was  redematous,  except  at  a  point  beneath  the  lateral  ventricle, 
where  there  was  a  circumscribed  patch  of  a  pinkish  hue,  which  seemed  to 
be  well  defined.  The  left  middle  cerebral  artery,  at  a  point  just  before  it 
gives  off  its  branches,  was  found  to  be  swollen  and  hard,  and  when  cut 
open  a  small,  rather  firm  clot  was  found.  Behind  this  there  was  a  long, 
stringy  clot  of  more  recent  date.  About  the  vessel  the  brain  was  cedema- 
tous.  Another  patch  of  red  softening  was  found  in  the  same  hemisphere 
somewhat  more  posteriorly.  No  other  large  arteries  were  affected,  but 
when  microscopically  examined,  I  found  considerable  occlusion  of  many 
small  capillaries,  and  great  disorganization  of  the  nerve  elements. 

I  have  seen  several  other  cases  of  this  kind  occurring  during  acute  dis- 
eases attended  by  a  hyperinosed  condition  of  the  blood. 

Causes Endocarditis  is,  above  all  other  causes  combined,  the  most 

important  and  common  in  the  production  of  embolism.  At  the  Patholo- 
gical Institute  of  Berlin1  there  were  300  cases  of  embolism  of  all  kinds 
associated  with  endocarditis  during  the  years  included  in  the  period  be- 
ginning 1868,  and  ending  1871.  Twenty  per  cent,  of  these  cases  were  of 
brain  embolism.  Of  a  large  number  of  cases  reported  in  the  London  Pa- 
thological Societies'  Transactions,  nearly  all  of  them  were  of  this  nature ; 
and  out  of  fifteen  cases  I  have  seen,  twelve  were  connected  with  disease 
of  the  heart,  and  generally  with  deposits  upon  the  mitral  valves. 

Croup,  the  puerperal  state,  phlebitis,  and  other  conditions  where  there 
is  any  tendency  to  the  formation  of  clots,  or  the  detachment  of  tissue 
which  finds  its  way  into  the  circulating  apparatus,  may  all  produce  em- 
bolism. 

Numerous  accidents  which    happen  through   carelessness,   or   perhaps 

1    Edinburgh  Med.  Journ.,  July,  1873. 


142  OCCLUSION    OF    INTRACRANIAL    VESSELS. 

unavoidable  injury  during  surgical  manipulation,  may,  by  the  introduction 
of  a  blood-clot  or  foreign  substance  into  the  circulation,  produce  an  occlu- 
sion of  some  cerebral  or  other  vessel.  This  accident  has  occurred  \vln-ii 
pressure  has  been  made  upon  large  aneurisms,  and  is  one  of  the  arguments 
against  the  intravenous  injection  of  substances  which  coagulate  the  blood, 
such  as  ergot,  persulphate  of  iron,  hair,  or  other  organic  substances. 

Dr.  Barker1  has  given  two  cases  of  embolism  following  the  parturient 
state,  and  Thomas  has  seen  one  or  more  cases  of  this  kind. 

As  to  age,  I  have  found  that  more  young  people  have  had  cerebral  em- 
bolism than  persons  of  advanced  life.  An  examination  of  twelve  cases 
reported  by  different  observers  gives  the  relative  frequency  as  follows: — 

Between  10  and  20  years  .         .       2          Between  40  and  50  years     .         .       2 
44        20    "    30 '  "      .         .       4  "        50    "    60  '  '4         .          .        1 

44         30     "     40     "       .          .3 

Of  these,  3  were  males,  and  9  were  females. 

Of  my  own  cases,  seven  were  between  twenty  and  thirty ;  five  between 
thirty  and  forty ;  and  three  between  forty  and  sixty.  Eight  were  women, 
and  the  others  men.  It  seems,  therefore,  that  the  period  between 
the  twentieth  and  thirtieth  years  is  that  in  which  the  disease  is  most 
common,  and  that  women  are  most  subject  to  the  disease.  According  to 
the  observations  of  medical  writers  in  general,  mitral  disease  is  more  often 
an  affection  of  youth  or  early  life  than  of  advanced  years;  so  it  seems 
probable  that  people  who  have  not  reached  middle  life  should  be  more 
subject  to  embolism. 

Diagnosis — The  important  distinction  is  to  be  made  when  we  suspect 
the  cause  to  be  one  of  cerebral  hemorrhage.  Next  in  order  come  throm- 
bosis, cerebral  congestion,  meningeal  hemorrhage,  and  cerebral  tumor. 

Gelpke*  has  given  the  following  table,  on  one  side  of  which  are  detailed 
the  features  of  cerebral  embolism;  on  the  other,  those  of  cerebral  hemor- 
rhage : — 

CEREBRAL    EMBOMSM.  CEREBRAL    HEMORRHAGE. 

Youth  of  patient.  Advanced  age,  atheroma. 

Sudden  onset  without  prodromata.  Prodromata  generally  present. 

Previous  articular   rheumatism,    val-         Hypertrophy  of  left  ventricle, 
vular  sounds. 

Previous  disease,   which    might  lead 
to  formation  of  clots. 

The  altnck.  The  attack. 

Extensive  muscular  paralysis  ;  amnc-  Symptoms  of  cerebral  pressure;  ataxic 

sic  aphasia.  aphasia;  involvement  of  the  intelligence. 

Very  rapid;  or  quite  imperceptible  Disappearance  of  the  residual  dis- 

disappearance  of  the  residual  disorder.  order  after  a  moderate  time. 

.Retention  of  early  mental  power.  Reaction  stage. 


Puerperal  Diseases,  p.  270. 

Archiv  der  Heilkunde,  xvi.,  Aug.  1875,  p.  485. 


EMBOLISM    OF    THE    CEREBRAL    VESSELS.  143 

Janeway1  relates  an  admirable  case  to  illustrate  the  obstacles  some- 
times encountered  in  making  a  diagnosis.  As  it  will  be  seen  in  his  case, 
there  were  many  circumstances  of  a  puzzling  character  which  made  the 
diagnosis  exceedingly  difficult. 

A  young  woman,  while  at  work,  fell  to  the  floor  unconscious,  in  what 
appeared  to  be  a  "  fainting  fit."  There  were  some  convulsive  movements 
limited  to  the  left  side  of  the  body.  When  admitted  to  Bellevue  Hospital 
on  the  following  day,  there  were  irregular  contraction  of  the  pupils,  coma, 
and  high  temperature.  A  loud  systolic  murmur  was  heard  all  over  the 
chest.  She  remained  unconscious  for  two  days,  and  on  the  third  day 
died.  Her  breathing  previous  to  death  was  stertorous,  her  limbs  flaccid, 
and  reflex  action  diminished.  The  pupils  were  dilated.  Her  urine  con- 
tained a  small  amount  of  albumen,  but  not  enough,  in  the  absence  of 
oedema  and  other  symptoms,  to  suggest  nephritic  trouble;  besides,  the 
quantity  of  urine  passed  was  sufficient.  The  question  of  thrombosis  was 
excluded  by  the  absence  of  premonitory  symptoms.  Congestive  chill, 
by  the  paralysis  and  meningeal  hemorrhage,  was  suggested,  but  excluded 
when  the  absence  of  rigidity  was  taken  into  account.  Janeway  considered 
the  lesion  to  be  hemorrhage,  and  I  will  give  his  own  description  of  the 
autopsy  and  its  result. 

"  The  post-mortem  examination  revealed  the  following:  Skull,  normal. 
Brain  and  membranes:  On  opening  the  dura  mater  on  the  right  side, 
a  clot  of  blood,  a  little  over  half  an  inch  thick,  three  inches  long, 
and  two  inches  wide,  escaped  from  the  arachnoid  sac.  This  clot  was 
in  the  main  black,  moderately  soft,  but  provided  with  a  bufly  coat  at 
one  portion.  It  had  produced  a  corresponding  depression  of  the  brain, 
over  which  it  was  situated,  and  in  its  centre  was  an  opening  about  an  inch 
long  and  a  half  inch  wide,  leading  from  a  recent  excavation  in  the  middle 
lobe  of  the  brain,  through  the  torn  pia  mater  and  so-called  arachnoid,  into 
the  sac  of  the  latter.  This  excavation  reached  from  the  convex  surface 
nearly  to  the  corpus  and  optic  thalamus  at  posterior  extremity.  The 
opening  was  situated  a  little  nearer  to  the  longitudinal  fissure  than  would 
correspond  to  the  middle  of  the  convex  surface.  The  excavation  was 
about  two  inches  wide  and  contained  clotted  blood,  of  which  some  had 
escaped  in  removing  brain.  The  brain-tissue  surrounding  this  was  soft, 
slightly  blood-stained,  and  where  it  formed  the  boundaries  of  the  space, 
numerous  black  points  were  present,  corresponding  to  clots  of  blood,  closing 
numerous  small  torn  vessels.  The  brain-tissue  of  the  posterior  lobe,  espe- 
cially on  its  outer  surface,  was  softer  than  natural.  The  posterior  ex- 
tremity of  the  optic  thalamus  of  the  right  side,  over  a  small  area,  presented 
an  ecchymotic  softened  state. 

"  In  the  clotted  blood  and  disintegrated  brain-tissue  found  at  the  mouth 
of  the  excavation,  a  small  branch  of  the  posterior  cerebral  was  found  torn 
across,  presenting  a  widened  extremity  at  the  point  of  rupture,  surrounded 
by  thickened  and  firm  tissue,  and  in  the  interior  of  this  a  firm  reddish- 
gray  clot,  uniform  in  its  structure  and  of  older  date  than  any  others.  I 
failed  on  careful  examination  to  find  the  other  extremity  of  the  torn  ves- 
sel, but  from  the  condition  of  the  portion  found  doubt  not  that  it  would 


1   Am.  Psychological  Journal,  Nov.  1876. 


144  OCCLUSION    OF    INTBACRANIAL    VESSELS. 

have  proved  of  similar  shape  to  the  other,  and  that  together  they  would 
have  constituted  a  cylindrical  dilatation  of  this  artery. 

"  The  left  (opposite)  hemisphere  showed  the  convolutions  flattened  and 
so  closely  pressed  together  laterally  as  to  nearly  obliterate  th<-  appearance 
of  sulci.  The  arachnoid  was  dry,  and  there  was  no  sub-arachnoid  fluid 
present.  The  brain  on  this  side  appeared  anaemic,  and  on  cutting  the 
dura  mater  pressed  out. 

"  The  lateral  ventricles  were  of  normal  appearance.  The  anterior  lobe 
of  right  side  was  normal.  Pons,  cerebellum,  etc.,  were  normal.  The 
arteries  at  the  base  were  carefully  examined,  being  followed  to  their  smaller 
ramifications  without  finding  any  emboli. 

"  The  lungs  were  slightly  oedematous. 

"Heart:  The  left  ventricle  was  slightly  hypertrophied.  On  the  auri- 
cular aspect  of  the  mitral  valve,  and  on  the  ventricular  of  the  aortic,  con- 
dylomatous  excrescences  were  present,  narrowing  both  orifices ;  but  the 
largest  mass  passed  obliquely  across  the  heart  from  the  leaf  of  aortic  valves 
nearest  the  septum  to  the  anterior  leaf  of  mitral  valves,  and  above  thi>. 
between  it  and  the  other  leaflet  of  aortic  valves,  a  slight  dilatation  of  the 
heart-wall  existed. 

"  Small  infarctions  were  present  in  the  spleen  and  the  kidney,  and  the 
latter  showed  at  some  points  interstitial  nephritis,  around  glomeruli,  with 
atrophy  of  these  ;  but  the  disease  was  not  advanced.  The  mesentery  pre- 
sented two  small  aneurismal  dilatations  of  little  arteries,  and  at  these 
points  emboli  were  present :  one  was  of  the  size  of  the  head  of  a  pin ;  the 
other,  of  a  pea. 

"  In  this  case  it  seems  exceedingly  probable  that  the  primary  lesion  of 
the  artery,  which  finally  ruptured,  was  embolism,  and  that  this  obstruction 
caused,  secondarily,  a  dilatation  of  the  artery  at  this  point,  and  that, 
owing  to  the  heat,1  such  an  obstruction  of  the  circulation  in  the  brain  oc- 
curred as  to  cause  the  rupture  of  the  vessel  described.  This  is  rendered 
still  more  probable  by  finding  two  small  arteries  in  the  mesentery  with 
aneurismal  dilatation,  and  containing  emboli. 

"  A  point  of  interest  in  this  case  is  the  absence  of  serious  symptoms  of 
cardiac  disease,  though  there  was  so  marked  a  lesion.  It  did  not  seem 
as  if  any  regurgitation  had  occurred  at  the  aortic  orifice,  simply  obstruc- 
tion. The  left  ventricle  contained  such  a  firmly  adherent  clot  that  the 
hydrostatic  test  was  of  no  avail. 

"  It  also  furnishes  another  to  the  already  long  list  of  cases  in  which  a 
heart-murmur  is  heard — sudden  paralysis  occurs — the  patient  moderately 
young,  and  yet  the  lesion  is  hemorrhage,  and  not  embolism.  I  have  met 
with  several  of  these  exceptions." 

From  thrombosis  there  will  be  no  difficulty  in  making  a  diagnosis  when 
we  remember  the  slow  origin  of  the  former.  The  "apoplectic  form"  of 
cerebral  congestion  sometimes  resembles  the  condition  presented  by  the 
patient;  however,  the  former  history,  the  suft'used  face,  contracted  pupils, 
and  rapid  subsidence  of  symptoms,  will  put  us  on  our  guard. 

1  The  weather  was  excessively  warm  at  this  time,  and  the  patient  was  at  first 
supposed  by  those  around  her  to  be  suffering  from  the  effects  of  the  heat. 


EMBOLISM    OF    THE    CEREBRAL    VESSELS.  145 

Morbid  Anatomy  and  Pathology — Burrowes  and  Kirkes  were- 
the  first  English  writers  and  Virchow  the  earliest  Continental  writer  to  de- 
scribe these  conditions.  Prevost  and  Cotard  have  since  related  interesting 
experiments.  They  injected  tobacco  seed  into  the  carotids  of  dogs,  and 
afterwards  watched  the  changes  that  followed.  One  of  these  do°-s  was 
killed  thirty-nine  days  after  the  seed  had  been  introduced,  when  they  found 
the  middle  cerebral  artery  obstructed,  and  induration  about  the  fissure  of 
Sylvius. 

The  pathological  processes  which  follow  such  mechanical  obstruction 
have  been  sufficiently  noticed  in  a  preceding  article,  so  it  will  be  enough 
to  call  attention  to  the  fact  that  the  consequence  of  such  an  accident  will 
be  softening  of  the  parts  deprived  of  their  nourishment,  unless  the  collat- 
eral circulation  be  established  at  an  early  date,  or  the  embolon  is  broken 
down  and  removed,  which  is  a  very  unlikely  circumstance. 

Kirkes1  calls  attention  to  the  distribution  of  emboli  in  the  following 
words:  "The  parts  of  the  vascular  system,  within  which  these  transmitted 
masses  of  fibrine  may  be  found,  will  of  course  depend  in  a  great  measure 
upon  whether  they  proceed  from  the  right  or  left  side  of  the  heart.  Then, 
if  they  have  been  detached  from  either  the  aortic  or  mitral  valves,  they 
will  pass  into  the  blood  propelled  by  the  left  ventricle  into  the  aorta  and 
its  subdivisions,  and  may  be  arrested  in  any  of  the  systemic  arteries  or 
their  modifications  in  the  various  organs,  especially  those  which,  like  the 
brain,  spleen,  and  kidneys,  receive  large  supplies  of  blood  directly  from 
the  left  side  of  the  heart.  If,  on  the  other  hand,  the  fibrinous  masses  are 
derived  from  the  pulmonary  artery  and  its  subdivisions  within,  the  lungs 
will  necessarily  become  the  primary  if  not  the  exclusive  seat  of  their  sub- 
sequent deposition." 

In  regard  to  the  side  of  the  brain  where  the  deposit  occurs,  I  think  we 
may  say  that  the  left  side  and  the  middle  cerebral  artery  are  the  most  com- 
mon site,  though  many  cases  reported  by  Shaw,  Glynne,  Murchison,  and 
others  prove  that  the  right  artery  may  be  affected  as  well. 

An  interesting  example,  which  is  almost  unique,  is  the  following  case 
of  embolism  of  the  right  posterior  cerebral  artery,  The  history  was  read 
by  Broadbent  before  the  London  Clinical  Society : — 2 

"  The  patient,  a  young  man  aged  19,  had  suffered  three  years  previously 
from  acute  rheumatism.  Ten  days  before  his  admission,  he  suddenly  be- 
came blind,  and  had  great  pain  in  the  head.  Five  days  later,  vision  hav- 
ing returned,  he  lost  the  use  of  his  left  limbs,  while  the  right  arm  and  leg 
were  continually  in  motion ;  and,  unless  restrained,  he  rolled  over  and 
over  towards  the  left,  falling  out  of  bed  and  bruising  himself  severely. 
The  left  hemiplegia  and  uncontrollable  movements  of  the  right  limbs  con- 
tinued when  he  was  admitted;  the  hemiplegia  not  being  absolute,  but 
accompanied  by  slight  rigidity  and  very  considerable  impairment  of  sensa- 
tion. The  patient  took  no  notice  of  persons  or  objects,  but  answered  ques- 
tions, and  put  out  the  tongue  on  being  urged.  His  pulse  was  variable, 

1  Royal  Med.  Clin.  Trans.,  vol.  xxxv.  p.  281,  1852. 

8  Abstracted  from  Lancet,  Monthly  Abstract,  April,  1876,  p.  576. 

10 


146  OCCLUSION    OF    INTRACRANIAL    VESSELS. 

120  to  100  or  more.  Temperature  in  the  right  axilla,  99.2°;  in  the 
left,  100.6°.  A  loud  mitral  systolic  murmur  was  present.  The  bowels 
were  confined,  and,  when  opened,  the  feces  and  urine  were  passed  in  bed. 
A  dose  of  three  grains  of  calomel  was  given,  and  two  grains  of  carbonate 
of  ammonia  with  two  drachms  of  infusion  of  digitalis  every  two  hour-. 
Chloral  also  was  given  at  night.  He  was  ordered  a  diet  of  milk  and  beef- 
tea,  with  four  ounces  of  brandy.  There  was  gradual  improvement;  and, 
three  days  after  his  admission,  an  ophthalmoscopic  observation,  previously 
attempted  in  vain,  was  obtained,  and  the  disks  were  found  to  present  the 
appearances  of  marked  ischaemia.  The  pulse  was  now  108,  soft,  short, 
and  strikingly  dicrotous.  A  day  later  the  pulse  was  88,  and  more  full. 
The  temperature  was  still  nearly  a  degree  higher  in  the  left  (100°)  than  in 
the  right  (99.2°)  axilla.  Slight  paralysis  of  the  left  external  rectus  of  the 
eye  was  observed.  At  the  end  of  a  fortnight's  stay  in  hospital,  the  right 
limbs  were  quiet,  and  there  was  considerable  return  of  power  and  sensation 
in  the  left  side.  His  speech  was  rather  slow,  but  there  was  no  obvious 
impairment  of  the  intellect.  Notwithstanding  this,  however,  he  not  only 
passed  his  feces  in  bed,  but  threw  them  about  and  bedaubed  himself  and 
the  bedclothes  without  any  regard  to  decency.  The  optic  ischaemia  was 
marked,  but  vision  was  good.  The  temperature  of  the  right  axilla  was 
99.3? ;  of  the  left,  100°.  At  the  end  of  three  weeks  he  passed  his  excretions 
naturally.  After  five  weeks  he  was  up  and  about,  eating  well;  but  pale, 
and  still  complaining  a  little  of  headache.  Impairment  of  power  and  of 
sensation  in  the  left  limbs  was  still  perceptible.  The  optic  neuritis  was 
subsiding.  Distant  vision  was  good,  but  small  print  was  not  easily  read. 
A  systolic  mitral  murmur  was  heard.  The  temperature  was  still  ne\i-r 
below  99°;  usually  100°;  it  was  now  equal  on  the  two  sides.  But  for 
this  elevation  of  temperature,  the  patient  would  have  been  allowed  to 
leave  the  hospital.  Soon  afterwards,  however,  there  were  symptoms  of 
splenic  embolism,  and  later  of  ulcerative  endocarditis ;  and  he  died  from 
this  four  months  after  admission.  On  post-mortem  examination,  with 
ulcerative  endocarditis  and  numerous  recent  embolisms,  there  was  found 
softening  of  the  occipital  lobe  of  the  right  hemisphere  from  the  posterior 
cornu  of  the  ventricle  downwards,  and  the  branch  of  the  post-cerebral 
artery  entering  the  calcarine  fissure  was  occluded  and  lost  in  adhesions. 
It  was  considered  probable  by  Dr.  Broadbent  that  originally  the  posterior 
cerebral  artery  itself  had  been  blocked  up,  and  not  only  this  branch.  The 
interesting  points  in  the  case,  on  which  comments  were  made,  were  the 
temporary  blindness,  the  agitation  of  the  right  limbs  and  rolling  tendency, 
the  usual  association  of  loss  of  sensation  and  of  double  optic  ischemia  with 
embolism  of  a  cerebral  artery,  and  the  remarkable  indifference  to  decency 
persisting  when  the  intellect  was  apparently  good." 

Fat  globules  may  sometimes  plug  up  the  small  capillaries,  producing 
wide  areas  of  softening. 

The  morbid  appearances  indicative  of  cerebral  embolism  are  of  interest 
and  worthy  of  the  closest  study,  not  only  because  the  brain  is  the  point 
which  suffers  the  most  seriously,  but  because  generally  the  heart,  spleen, 
lungs,  bloodvessels,  and  other  organs  may  be  involved  as  well.  On-the  valves 
of  the  heart,  either  mitral  or  aortic,  may  be  found  excrescences,  induration 
or  recent  clots,  and  the  arteries  themselves  may  exhibit  patches  of  atheroma. 
In  the  brain  we  will  probably  find  one  or  more  of  the  arteries  I  have 


EMBOLISM    OF    THE    CEREBRAL    VESSELS.  147 

spoken  of  to  be  swollen,  hard,  and  filled  by  one  of  these  little  masses  of 
fibrine.  They  have  been  compared  to  grains  of  wheat,  and  resemble  them 
very  closely.  Generally  the  embolon  is  separated  from  a  second  plug 
which  has  followed  clotting  of  the  arrested  blood.  Emboli  are  never 
attached  to  the  walls  of  the  vessels. 

Several  arteries  may,  perhaps,  be  found  obstructed  in  the  same  way. 
"  Sometimes  all  on  one  side  ;  at  other  times  some  arteries  of  one  side  of  the 
brain,  and  some  of  the  other,'"  so  says  Fox. 

Softened  masses  are  generally  found  on  examination,  and  are  usually 
the  cause  of  death.  The  parts  behind  the  occlusion  are  subjected  to  the  full 
force  of  blood  which  is  arrested,  and  not  sent  to  the  parts  it  should  supply, 
and  local  hypersemia  is  a  result.  The  resulting  softening  is  generally  con- 
fined to  the  left  hemisphere  at  its  base,  for  reasons  I  have  before  stated, 
and  the  frontal  convolutions,  corpus  striatum,  and  adjacent  parts  are  found 
to  be  either  red  or  yellow,  softened  or  indurated. 

(Edema  of  the  brain  is  not  an  uncommon  appearance,  such  oedema 
being  seen  in  the  parts  deprived  of  blood.  The  perivascular  spaces  being 
enlarged,  it  is  but  natural  that  their  fluid  should  rush  in  to  fill  up  the  in- 
creased space  left  by  the  bloodless  arteries. 

Prognosis — The  outlook  for  the  patient  is  generally  a  very  gloomy 
one  if  the  accident  be  at  all  grave,  and  the  artery  be  one  of  importance. 
The  severity  of  the  symptoms,  the  existence  of  emboli  in  other  organs, 
the  element  of  severe  pain,  high  temperature,  and  gradual  development  of 
symptoms  indicative  of  softening  are  of  unfavorable  import,  and  give 
affairs  a  very  dark  look ;  therefore  it  is  never  well  to  make  too  hasty  a 
prognosis. 

Treatment Rest,  abstinence  from  stimulants,  and  agents  which  will 

diminish  the  arterial  tension  are  the  only  remedial  means  to  adopt  besides 
the  ordinary  indications  which  appeal  to  the  common  sense  and  discretion 
of  the  medical  man.  Afterwards,  resulting  conditions,  such  as  paralysis 
or  softening,  are  to  be  treated. 

1  Op.  cit.,  p.  32. 


148  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 


CHAPTER   Y. 

DISEASES  OF  THE  CEREBRUM  AND  CEREBELLUM  (CONTINUED). 
CEREBRAL  SOFTENING. 

Synonyms — Ramollissement  (rouge,  blanc,  jaune).  Encephalitis 
aigue,  chronique  (Fr.).  Mollities  cerebri,  Encephalitis,  Softening  of  tin- 
Brain  (chronic,  acute),  Inflammation  of  the  Brain. 

Definition — A  disease  of  the  brain  of  an  acute  or  chronic  character, 
attended  by  destruction  of  nervous  substance,  and  of  an  acute  inflammatory 
nature,  with  purulent  formation  ;  or  of  a  chronic  non-inflammatory  charac- 
ter, with  less  rapid  disorganization  of  nerve-tissue ;  but  in  either  case  pro- 
ductive of  a  mollification  of  the  nervous  substance. 

So  much  confusion  has  arisen  from  an  incorrect  appreciation  of  the 
morbid  anatomy  and  its  connection  with  pathology,  that  it  is  a  difficult 
matter  to  attempt  the  reconciliation  of  the  many  widely  differing  views  of 
the  legion  of  writers.  "Inflammation  of  the  brain"  is  the  term  which  lias 
led  to  all  this  confusion  ;  and  I  have  been  bold  enough  to  base  my  classi- 
fication rather  upon  the  character  of  tissue-changes  than  upon  the  arbitrary 
law  that  softening  of  the  brain  is  the  only  result  of  inflammation.  Sclero- 
sis, as  we  know,  is  undoubtedly  the  result  of  a  low  grade  of  inflammation, 
but  in  this  case  the  tissue-changes  are  quite  different. 

Considering  that  the  word  "  softening  "  means  a  mollification,  and  that 
it  may  result  not  only  from  purulent  inflammation,  but  from  low  nutritive 
changes,  I  shall  divide  the  subject  as  follows : — 

1.  Acute  Softening,          (      Diffiised  Cerebritis. 
(Inflammatory),  Meningo-Cerebritis. 

Purulent  Cerebritis. 

2.  Chronic  Softening,       <      Primary  Softening. 
(Non-inflammatory),    <      Secondary  Softening. 

1.  Under  the  first  head  we  may  place  the  variety  described  by  Elam,1 
which  is  a  quite  rare  affection  in  its  uncomplicated  form,  that  is,  when -it 
involves  the  brain  substance  en  masse;  and  meningo-cerebritis,  which  is 
by  far  more  common.     In  a  third  variety  the  acute  disease  is  characterized 
by  purulent  collections,  and  perhaps  by  the  ultimate  formation  of  abscesses 

2.  Chronic  softening  in  its  primary  form  we  will  consider  to  be  depend- 
ent upon  general  disease,  intellectual  prostration,  and  like  causes ;  while 
"  secondary  softening"  may  be  used  to  express  the  form  which  follows 
vascular  lesions,  such  as  embolism,  thrombosis,  or  cerebral  hemorrhage. 


1  Cerebria,  and  other  Diseases  of  the  Brain,  London,  1872. 


•/ 


ACUTE    SOFTENING. 


ACUTE  SOFTENING. 

In  the  first  form  it  may  be  either  cortical,  diffused,  or  combined  with 
meningitis. 

Symptoms — Cerebritis  of  either  kind  is  preceded  in  nearly  every 
instance  by  symptoms  of  functional  disorder,  such  as  cerebral  congestion 
or  cerebral  anaemia,  but  these  are  not  sufficient  in  themselves  to  arouse  the 
suspicion  of  the  observer  as  to  the  serious  character  of  the  disease  which 
is  to  follow.  The  later  prodromata  of  cerebritis,  however,  cannot  be  mis- 
taken, and  finally  the  developed  disease  presents  most  pronounced  symp- 
toms, which,  if  they  do  not  always  enable  us  to  locate  the  brain  lesion,  are 
sufficient  to  assure  us  that  some  violent  inflammatory  process  is  under 
-weigh  in  the  cerebral  mass.  The  patient  may  for  some  months  suffer 
greatly  from  headache  of  a  diffused  character,  accompanied  by  burning 
sensations,  and  a  sense  of  pressure  behind  the  eyeballs.  These  headaches 
are  quite  intense,  and  are  aggravated  by  exposure  to  heat,  concentration 
of  the  mental  powers,  and  alcoholic  indulgence.  His  memory  becomes 
gradually  enfeebled,  so  that  at  first  dates  and  names  are  forgotten,  and 
afterwards  faces,  locations,  and  even  information  which  may  have  been 
imparted  to  him  a  short  time  previously.  Some  slight  clumsiness  of 
speech  may  be  indicative  of  the  near  approach  of  grave  symptoms,  but 
this  clumsiness  is  not  aphasic  till  later.  Irritability  of  temper,  restless- 
ness, and  incapacity  for  mental  application  are  attendant  evidences  of  the 
smouldering  fire  which  afterwards  is  to  make  itself  known  by  still  more 
decided  symptoms.  Among  these  may  be  enumerated  nystagmus,  stra- 
bismus, and  diplopia,  as  ocular  troubles ;  contractures  of  the  limbs, 
tremors  of  individual  muscles  or  groups  of  muscles,  a  twitching  of  the 
limbs,  or  other  motor  troubles,  and  hyperaesthesia,  followed  by  anaesthesia, 
and  other  disorders  of  sensation;  these  last  sometimes  being  peculiarly 
prominent.  Next  we  find  that  there  may  be  an  apoplectic  attack  or 
convulsions  of  an  epileptiform  character,  which  mark  the  violent  stages  of 
the  disease.  Should  there  be,  as  a  result  of  the  morbid  process,  cerebral 
hemorrhage,  it  will  be  found  that  the  paralyzed  limbs  become  markedly 
contracted,  and  that  rigidity  is  a  striking  feature.  According  to  Jaccoud, 
the  contractures  may  be  bilateral,  though  the  rule  is  the  other  way,  the  limbs 
of  but  one  side  being  rigidly  flexed.1  He  has  seen  one  case  where  the 
left  arm  and  leg  were  the  seat  of  contractures,  and  where  the  face  was 
contracted  and  strongly  drawn  towards  the  left  side,  suggesting  a  right 
facial  palsy,  but  the  appreciable  rigidity  of  the  facial  muscles  of  the  left 
side  left  no  doubt  as  to  the  origin  of  the  deviation.  The  paralyzed  mem- 
bers are  generally  those  that  are  the  seat  of  convulsive  movements  in  the 
first  place.  The  convulsions  may  be  general,  and  assume  an  epileptiform 
character,  and  may  be  accompanied  by  vomiting.  The  patient's  mental 
condition  meanwhile  undergoes  a  great  change.  Delusions,  which  somewhat 

1  Trait6  de  Path.  Interne,  vol.  i.,  art.  Enceph.  algue. 


150  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

resemble  those  of  general  paralysis  of  the  insane,  are  present ;  the  exaltation 
delirante  of  the  French,  which  is  by  some  considered  to  be  an  early  symptom. 
This  has  not  been  my  experience,  and  I  am  convinced  that  in  the  cases  where 
it  has  been  noticed  as  an  early  expression  of  the  affection,  the  disease 
was  probably  general  paralysis,  and  not  cerebritis.     Memory  is  abolished, 
and  finally  dementia  remains,  which,  should  the  patient  live  for  some  time, 
is  expressed  by  all  the  other  signs,  drivelling  of  saliva,  inane  smile,  hebetude, 
and  total  imbecility,  while  there  may  be  aphasia  of  the  amnesic  or  ataxic 
variety.      The  muscles  concerned  in  articulation  and  deglutition  are  in- 
volved, and  the  patient  may  narrowly  escape  being  choked  by  the  masses 
of  food  which  "  go  down  the  wrong  way  "  or  accumulate  in  his  mouth. 
Constipation  or  retention  of  urine  is  not  an  uncommon  accompaniment, 
and   the  urine  is  charged  with  urates,  is  dark-colored,  and  rapidly  under- 
goes decomposition.     The  temperature  and  pulse  are  both  changed,  t In- 
latter  becoming  accelerated  and  irregular,  and  the  heart-sounds  sharp  and 
"  precipitative."     A  tremulous  character  of  the  pulse  has  been  noticed  by 
several  observers ;  but  I  agree  with  Hammond  that  there  is  nothing  dis- 
tinctive about  this.     The  temperature  may  rise  to  110°  F.,  and  generally 
attains  its  highest  point  at  the  end  of  the  first  four  days.     Coma  precedes 
a  fatal  ending  in  the  acute  form  at  the  end  of  a  few  days,  and  death  occurs 
generally  after  seven  or  eight  days  by  asphyxia.     Should  the  patient  sur- 
vive, there  is  a  remission  of  the  symptoms,  and  the  formation  generally  of 
an  abscess.     Cerebritis  does  not  always  begin  in  the  same  way,  and,  as  I 
have  already  stated,  is  not  invariably  symptomatized  by  all  the  forms  of 
disordered  functions  I  have  enumerated.     There  may  be  no  premonitory 
symptoms  should  the  disease  follow  otitis  or  injury,  but  in  the  insidious 
form,  which  has  been  so  admirably  described  by  Klam  and  Reynolds,  the 
appearance  of  prodromata  is  gradual  and  progressive.     In  certain  cases 
the  paralysis  is  an  early  symptom,  in  others  the  defects  of  articulation  and 
deglutition  are  more  prominent ;  in  other  cases  psychical  disturbances  are 
decided,  while  in  still  others  coma  or  convulsions  are  the  striking  features. 
The  predominance  of  these  different  symptoms  depends  very  much  upon 
the  region  which  suffers  the  most  from  the  violence  of  inflammatory  action. 
It  must  be  borne  in  mind  that  the  disorder  is  attended  from  the  first  by 
febrile  disturbances,  and  that  all  the  symptoms  are  those  indicative  of  a 
hypenvsthetic  state  of  the  cerebrum.     Should  the  patient  survive  the  im- 
mediate violence  of  the  attack,  he  may  recover  to  some  degree.    The  tem- 
jKTature  and  pulse  are  lowered ;  the  active  evidence  of  the  central  disease 
subsides,  but  it  is  not  common  for  any  amelioration  of  the  paralysis  to  take 
place.     The  headache  may  become  more  localized  and  less  intense,  or  may 
subside  altogether,  and  it  mfvy  only  reappear  when  the  patient  is  fatigued. 
lie  may  remain  in  this  condition  for  several  years.    In  one  case  that  came 
under  my  observation  I  accidentally  found  a  large  abscess  about  the  size 
of  a  horse  chestnut  in  the  white  matter  of  the  anterior  lobe  of  the  right 
hemisphere.     The  individual  had  died  of  phthisis,  and  during  life  com- 
plained of  no  symptoms  which  would  direct  suspicion  to  the  brain  lesion. 
He  had  had  a  febrile  attack  six  years  before,  which  was  probably  the  time 


ACUTE    SOFTENING.  151 

at  which  the  abscess  was  formed.  In  many  cases  cerebral  abscess  follows 
disease  of  the  temporal  bone,  and  in  the  majority  of  instances  it  is  not 
essentially  necessary  that  there  should  be  complicating  general  meningitis, 
though  such  is  often  the  case.  A  very  interesting  history  was  presented 
by  Dr.  Elliot1  to  the  New  York  Pathological  Society. 

A  man  aged  50,  of  intemperate  habits,  for  the  last  twenty  years  subject 
to  constant  headache,  fourteen  years  ago  had  an  attack  of  acute  mania, 
lasting  two  weeks,  and  ten  years  ago  a  similar  attack.  For  the  last  four 
months  vision  has  been  failing,  and  there  was  an  inclination  to  talk  con- 
tinually, either  to  himself  or  the  attendants. 

One  month  before  death  he  was  seized  with  general  convulsions.  A 
week  later  there  was  spasm  of  the  left  leg,  attended  with  intense  pain, 
alternating  for  three  days  with  pain  in  the  lumbar  region,  and  imperfect 
paraplegia,  terminating  in  paralysis  of  the  left  leg;  this,  however,  passed 
off  in  twenty-four  hours. 

One  week  before  death  there  was  convulsive  action  of  the  right  side, 
with  severe  pain  for  two  hours,  succeeded  by  right  hemiplegia.  After 
thirty-six  hours,  motion  was  regained  in  the  arm,  but  not  in  the  leg.  Dur- 
ing the  last  month  of  life  there  was  constant  vomiting. 

Autopsy — There  was  found  near  the  centre  of  the  upper  surface  of  the 
right  middle  cerebral  lobe  a  thickening  of  the  arachnoid,  and  beneath  this 
an  abscess  of  the  size  of  an  English  walnut,  with  smooth  walls.  The 
brain-substance  surrounding  the  abscess  was  condensed  and  gray,  and 
around  this  again  red  and  soft.  In  the  centre  of  the  right  middle  cerebral 
lobe,  in  the  anterior  and  inferior  part  of  the  right  posterior  cerebral  lobe, 
in  the  centre  of  the  left  middle  lobe,  and  in  the  inferior  part  of  the  left 
middle  lobe,  were  similar  abscesses. 

The  left  lateral  ventricle  was  filled  with  pus  coming  from  the  abscess 
in  the  left  middle  lobe ;  the  pus  in  all  the  abscesses  was  green  and  fetid. 
No  lesions  were  found  in  the  other  organs. 

Causes. — Exposure  to  the  sun's  rays,  alcoholism,  inflammatory  disease 
of  the  bones  of  the  head  or  face,  meningitis,  brain  tumors,  traumatism, 
and  syphilis,  as  well  as  several  of  the  zymotic  fevers  and  rheumatism,  are 
all  predisposing  and  exciting  causes  of  cerebritis.  The  simple  form  may 
be  idiopathic,  but  that  which  results  in  the  production  of  abscesses  is  more 
often  due  to  traumatism,  caries  of  adjacent  bones,  or  syphilis.  Jaccoud 
has  found  that  the  proportion  of  patients  in  regard  to  sex  was  in  favor  of 
the  males,  nine  men  being  affected  to  every  four  women,  and  that  the  dis- 
ease was  developed  between  puberty  and  the  forty-fifth  year.  Cerebral 
abscess  or  traumatic  cerebritis  may  be  produced,  of  course,  at  any  age  by 
injuries  or  the  extension  of  other  diseases.  I  have  seen  one  case  in  which 
cerebritis  followed  otitis  in  a  child  ten  years  old.  Lead  poisoning  should 
not  be  forgotten  as  a  rare  cause. 

Morbid  Anatomy  and  Pathology — Cerebritis  may  either  in- 
volve the  cortex  cerebri  or  some  central  parts,  such  as  the  corpora  striata 
or  optic  thalami,  or  more  rarely  may  affect  the  entire  brain,  but  it  prefers 
the  gray  matter,  which  is  so  richly  supplied  by  bloodvessels.  The  brain 
may  be  found  to  be  the  seat  of  many  softened  parts,  as  "foyers"  of  purulent 

1  Trans.  N.  Y.  Path.  Soc.,  vol.  i.  p.  C. 


152  DISEAS£S   OF    THE    CEREBRUM    AND    CEREBELLUM. 

accumulation,  serous  exudation  from  the  vessels,  infiltrating  the  surround- 
ing brain-tissue,  or  there  may  be  ruptured  vessels,  and  an  escape  of  thi-ir 
contents.  The  brain-tissue  may  be  stained  by  the  hematine,  and  occa- 
sionally present  the  appearance  .of  simple  non-inflammatory  softening. 
The  microscope  enables  us  to  see  a  multiplicity  of  changes — granular 
degeneration,  leucocytes,  broken-down  nerve-elements,  rarely  neuroglia- 
thickening,  and  still  more  rarely  amyloid  bodies.  I  know  of  no  more  in- 
teresting field  for  the  study  of  morbid  microscopical  anatomy  than  a  brain 
of  this  kind,  for  nearly  every  appearance  or  grade  of  diseased  structure  may 
be  found.  The  vascular  lesions  are  capillary  hemorrhage,  miliary  aneu- 
rism, etc.  Suppuration  takes  place  in  several  ways.  The  brain-sub- 
stance may  be  generally  infiltrated,  so  that  it  presents  a  yellow  color 
throughout  its  extent,  or  there  may  be  a  localized  infiltration  or  an  en- 
cysted collection  of  pus.  About  the  latter  will  be  found  a  sclerosis  of  the 
brain-tissue,  and  about  this  a  serous  infiltration.  Jaccoud  has  found  that 
abscesses  are  more  often  to  be  observed  in  the  white  substance,  in  which 
conclusion  he  is  supported  by  the  observations  of  many  writers.  Lebert,1 
in  fifty-eight  cases,  found  the  abscess  to  be  located  twenty-three  times  in 
the  left  hemisphere,  eighteen  in  the  right,  twice  in  the  corpora  striata, 
twelve  times  in  the  cerebellum,  twice  in  the  pituitary  body,  and  once  in 
the  spinal  cord.  I  have  already  presented  cases  which  will  enable  the 
reader  to  appreciate  the  origin  and  size  of  such  collections  of  purulent 
matter,  and  the  evidences  of  diseased  bone,  fracture,  etc.,  that  are  to  be 
discerned  in  cases  of  traumatism  or  disease.  In  certain  pynemic  condi- 
tions, such  as  erysipelas,  abscesses  may  be  found  in  other  parts  of  the 
body  as  well,  notably  in  the  liver  and  lungs.  In  rare  forms  a  rapid  ne- 
crobiosis  or  "  death"  of  tissues  takes  place,  which  is  almost  analogous  with 
gangrene  in  other  parts  of  the  body,  and  large  masses  of  brain-tissue  are 
destroyed  very  rapidly.2 

1  Virchow's  Archiv,  x.  1866. 

*  Of  fifteen  cases  of  cerebral  softening  of  the  acute  form,  Camleil*  found  in  one 
fibrine  in  the  sinuses  of  the  dura  mater ;  in  one,  this  membrane  was  bathed  in 
purulent  liquid,  and  it  was  also  perforated  at  one  point;  in  five  there  were  recent 
spots  of  encephalitis  on  the  right  and  left  sides,  in  six  on  the  left  only,  in  three  on 
the  right  only ;  in  three  there  were  cellular  cicatrices  in  the  right  lobe  of  the 
brain,  in  one  in  the  left  lobe ;  in  two  the  right  hemisphere  of  the  cerebellum  was 
the  seat  of  an  acute  inflammatory  spot ;  in  four  the  principal  recent  inflammatory 
spots  were  still  in  a  state  of  red  hepatixation  ;  in  seven  they  were  in  a  state  of 
softening,  with  disintegration  of  the  nervous  substance  ;  in  four  they  were  in  a 
state  of  disintegration  of  the  nervous  substance,  with  a  mixture  of  a  liquid  that 
resembled  pus  ;  in  four  the  spots  of  acute  local  encephalitis  without  clot  were 
studied  microscopically.  Of  these,  in  one  they  were  still  in  the  state  of  red 
hepati/ation  ;  the  diseased  regions  were  reddened  by  the  widening  of  the  capilla- 
ries, and  by  the  presence  of  extravasated  globules  of  blood  ;  the  cerebral  fibres 
were  not  yet  disintegrated  ;  already  small  granular  cells  had  begun  to  be  formed 
in  the  inflamed  parts.  In  three  the  nervous  substance  of  the  diseased  seats  was 
disintegrated,  and  more  or  less  reduced  to  fragments ;  it  was  soaked  in  plasma, 


*  Quoted  by  Fox. 
I 


ACUTE    SOFTENING.  153 

Diagnosis. — Cerebral  hemorrhage,  meningitis,  cerebral  tumor,  embo- 
lism, and  thrombosis  are  all  conditions  from  which  it  is  proper  we  should 
distinguish  acute  cerebritis  and  cerebral  abscess. 

Some  of  the  symptoms  of  general  paralysis  of  the  insane  may  possibly 
mislead  the  observer.  From  cerebral  hemorrhage  we  are  to  distinguish 
cerebritis  by  the  rapid  amendment  of  symptoms  in  the  former,  while  in 
the  latter  there  is  progressive  evidence  of  advancing  structural  changes. 
Fever  is  not  connected  with  cerebral  hemorrhage,  unless  there  be  secon- 
dary inflammation  of  the  brain-substance.  The  headache  is  not  suggestive 
of  cerebral  hemorrhage,  nor  is  the  delirium  or  vomiting;  and,  after  all, 
the  only  symptom  which  deserves  attention  is  the  paralysis.  It  is  impor- 
tant to  bear  in  mind  that  rigidity  and  contracture  take  place  before  pa- 
ralysis, while  we  know  that  the  converse  is  the  rule  in  cerebral  hemorrhage. 
Should  hemiplegia  follow  a  number  of  the  other  symptoms,  we  may  consider 
that  the  hemorrhage  is  secondary  to  the  cerebritis,  and  that  some  vessel 
has  been  cut  across.  It  is  almost  impossible  to  distinguish  uncomplicated 
cerebritis  from  meningo-cerebritis.  The  pain  is  perhaps  more  marked  in 
the  latter,  and  the  convulsions  are  bilateral.  In  uncomplicated  cerebritis 
there  is  not  nearly  so  much  fever  as  in  the  meningeal  form  or  in  simple 
meningitis.  Typhoid  fever  may  simulate  cerebritis,  and  vice  versa, 
Attacks  of  the  latter  begin  with  headache,  vertigo,  movements  of  the  eyes, 
insomnia,  delirium,  nose-bleed,  and  diarrhoea,  with  high  evening  tem- 
perature. The  absence  of  tympanites,  and  gurgling  in  the  left  iliac  fossa, 
and  the  appearance  of  paralysis  and  visual  disorders,  are  quite  sufficient 
landmarks  to  prevent  the  diagnostician  from  losing  his  way.  When  there 
is  suspicion  of  otitis  or  traumatism,  it  is  exceedingly  difficult  to  make  a 
diagnosis  from  thrombosis  of  the  cerebral  sinuses,  and  it  is  fortunate  that 
no  value  is  to  be  attached  to  such  a  diagnosis,  as  far  as  therapeutical  indi- 
cations are  concerned. 

Prognosis There  is  very  little  hope  for  the  patient,  and  should  he 

survive  the  acute  attack  he  is  usually  left  paralytic  and  demented.  If 
there  be  a  purulent  accumulation,  which  becomes  encysted,  the  chances  of 
recovery  are  very  little  better,  and  it  only  becomes  a  question  of  time 
when  the  patient  will  die.  If  there  be  such  a  cerebral  abscess,  subsequent 
symptoms  very  much  like  those  connected  with  other  brain  tumors  will  be 
probably  developed ;  but,  in  numerous  cases  cited  by  various  authors,  a 
cerebral  abscess  has  existed  unsuspected  for  years. 

Treatment Acute  cerebritis  in  either  form  must  be  met  with  ab- 
straction of  blood,  cold  effusions  to  the  head,  agents  which  lower  vascular 
tension,  counter-irritants,  and  mercury  in  some  one  of  its  forms.  The 
ice-bag,  or  the  apparatus  already  alluded  to  for  the  application  of  cold 
water,  may  be  used,  and  leeches  are  to  be  applied  to  the  arms  or  behind 
the  ears.  Jaccoud  and  most  of  the  clinical  teachers  recommend  purgation, 

mixed  with  a  considerable  number  of  great  cells  collected  together,  and  molecular 
granules  ;  sometimes  in  the  preparation  there  were  seen  rare  globules  of  pus  scat- 
tered. The  vessels  and  their  principal  branches  were  constantly  very  apparent. 


154  DISEASES   OF    THE    CEREBRUM    AND    CEREBELLUM. 

which  may  be  obtained  by  the  use  of  the  compound  jalap  powder,  followed  by 
calomel  carried  almost  to  the  point  of  salivation.  This  seems  to  me  to  be 
rather  energetic  treatment ;  and  I  think  that  the  purgative  alone,  with  just 
sufficient  calomel  afterward  to  insure  a  continued  free  action  of  the  bowels, 
is  preferable.  For  the  purpose  of  diminishing  vascular  tension,  either  fjirtar 
emetic  (F.  35),  aconite,  or  veratrum  viride  (F.  36)  may  be  used.  Should 
the  cerebritis  be  found  to  depend  upon  syphilis  or  lead,  the  iodide  of  potas- 
sium may  be  employed  as  the  most  serviceable  remedy.  Blood-letting  is 
admissible  in  serious  cases,  and  is  recommended  by  nearly  all  of  the  older 
writers.  The  head  may  be  shaved  and  blistered,  or  cauterized  ;  but  I  .mi 
convinced  that  sub-occipital  vesication  is  in  every  way  as  good,  and  the 
infliction  of  this  punishment  is  not  warranted.  If  there  be  any  otitis,  it 
is  well  to  promote  otorrhcea ;  or,  if  there  be  a  collection  of  pus  beneath  a 
depressed  and  fractured  bone,  it  may  be  liberated  by  a  free  incision. 


CHRONIC    SOFTENING. 

Definition — A  disease  of  the  brain  of  a  very  serious  character,  gene- 
rally of  a  secondary  nature,  and  dependent  upon  impaired  nutrition  of  the 
brain-substance  through  occlusion  of  the  cerebral  vessel,  and  symptom- 
atized  by  a  numerous  variety  of  mental,  sensorial,  and  motorial  symptoms. 
Much  confusion  has  resulted  from  the  use  of  a  variety  of  terms,  such  as 
"  red  softening,"  "  white  softening,"  "  inflammation  of  the  brain,"  and 
other  names  which  tend  to  mislead  the  student.  For  our  purpose  it  will 
do  to  consider  white  and  red  softening  as  different  stages  of  the  same  con- 
dition, which  may  result  from  a  variety  of  causes  ;  and  inflammation  of  the 
brain  more  as  the  condition  which  I  have  just  described  than  that  of  which 
I  propose  to  speak,  viz.,  the  variety  spoken  of  by  Reynolds  and  others  as 
."  non-inflammatory  softening." 

Symptoms — The  symptoms  of  softening  of  the  brain  may  follow  a 
cerebral  hemorrhage,  embolism,  or  thrombosis,  or  perhaps  be  connected 
with  symptoms  of  cerebral  tumor  ;  or,  again,  cerebritis  may  leave  behind 
it  a  chronic  condition  expressed  by  the  symptoms  I  am  about  to  detail. 
The  early  troubles  of  the  primary  form  are  those  of  intelligence ;  the 
patient  becomes  silly,  loses  his  memory  of  events  which  have  recently 
transpired,  is  unable  to  concentrate  his  attention,  and  becomes  restless  and 
irritable,  quarrelling  with  his  immediate  friends,  and  getting  quite  excited 
towards  night.  His  speech  may  become  affected,  and  he  sits  by  himself 
for  hours  during  the  day,  and  mutters  constantly  a  mass  of  disconnected 
rubbish.  This  condition  of  stupidity  increases ;  he  may  become  drowsy 
and  complain  of  headache,  with  feelings  of  head-pressure ;  he  may  tell  us 
that  his  limbs  feel  heavy,  and  complain  of  muscular  pain,  from  which  he 
suffers  in  the  attempt  to  make  any  movement.  As  to  other  sensory  dis- 
turbance, hy|>era?sthesia  is  much  more  common  than  anaesthesia ;  though 
cutaneous  areas,  in  which  sensation  is  impaired,  are  by  no  means  rare. 
Motorial  troubles  are  of  later  appearance,  commencing  with  gradual  loss 


CHRONIC    SOFTENING.  155 

of  power  of  an  irregular  character,  which  may  affect  either  the  arms  or  legs 
in  the  beginning,  but  finally  becomes  general.  This  paralysis  is  not  always 
constant,  there  being  a  greater  loss  of  power  at  times  than  at  others. 
The  first  indication  of  the  motorial  trouble  may  appear  either  in  the  exe- 
cution of  some  ordinary  act,  which  will  be  performed  very  clumsily ;  or  in 
locomotion,  when  the  patient  will  stumble  or  fall  to  the  ground,  as  there 
may  be  a  sudden  giving  way  at  the  knee.  When  he  walks  he  scarcely 
lifts  his  feet  from  the  ground,  but  drags  them  after  him  in  a  helpless 
manner.  With  the  paralysis  there  may  be  a  certain  amount  of  rigidity, 
or  tonic  spasms,  affecting  the  muscles,  so  that  there  are  occasionally  spastic 
contractions,  which  last  for  some  little  time.  Epileptiform  convulsions  may 
occur  during  the  disease,  as  well  as  attacks  of  mania,  which  are  quite  vio- 
lent. When  the  softening  is  secondary,  and  follows  an  attack  of  embolism, 
thrombosis,  or  cerebral  hemorrhage,  the  initial  symptoms  make  their  ap- 
pearance in  from  one  to  two  weeks  after  the  occurrence  of  the  hemiplegia. 
The  troubles  of  intelligence  are  those  which  first  attract  our  attention,  and 
are  generally  connected  with  high  temperature  and  severe  headache.  The 
patient  may  become  delirious ;  he  indulges  in  delusions,  and  grows  ab- 
normally sensitive ;  or,  on  the  other  hand,  he  is  drowsy,  stupid,  and 
melancholic ;  and  after  this  may  follow  paralytic  contractures,  clonic 
spasms,  convulsions  resembling  epilepsy,  or  fibrillary  contractions  ;  and  he 
may  finally  become  comatose.  It  is  not  uncommon  for  the  patient  to  in- 
voluntarily pass  his  feces  and  urine.  With  the  formation  of  cysts  or  ab- 
scesses, which  constitute  a  late  result  of  cerebral  softening,  convulsions  of 
an  epileptoid  character  may  make  their  appearance ;  or,  should  the  con- 
dition be  acute,  and  result  from  otitis,  as  is  the  case  in  cerebritis,  these, 
as  well  as  other  symptoms,  may  be  among  the  first  to  develop.  Affections 
of  speech  are  quite  symptomatic  of  softening,  because  in  so  many  of  the 
cases  the  middle  cerebral  artery  is  that  obstructed  or  destroyed.  The 
hemiplegia,  which  may  occur,  is  unattended  by  any  loss  of  consciousness, 
and  electro-muscular  contractility  is  generally  perfect  or  even  exaggerated. 
The  following  may  be  presented  as  an  illustrative  case  : — 

J.  A.,  aged  45.  The  patient  was  brought  to  me  by  his  wife  during  the 
summer  of  1872.  Four  years  before,  while  actively  engaged  in  business 
which  demanded  the  most  devoted  attention,  and  required  a  great  deal  of 
intellectual  labor,  he  began  to  suffer  from  headaches  limited  to  the  frontal 
region.  These  were  so  severe  that  while  engaged  in  his  office  he  was 
obliged  to  bind  a  wet  towel  about  his  head.  He  suffered  very  greatly 
from  insomnia,  and  found  it  impossible  to  sleep  unless  he  took  large  doses 
of  opium.  He  very  often  awoke  in  the  night,  and  went  upon  the  house- 
top or  out  into  the  street,  wandering  about  the  city  until  morning.  He 
became  very  moody,  treated  his  wife  with  indifference,  and  scolded  his 
children  without  cause.  He  could  not  talk  for  five  minutes  at  a  time 
without  rising  and  pacing  furiously  about  the  room,  while  he  seemed  to 
be  annoyed  by  the  slightest  noises  about  the  house.  The  trickling  of 
water  from  the  pipe  over  the  water-closet  tank,  which  was  next  to  his 
bedroom,  so  annoyed  him  that,  in  a  fit  of  impatience  and  ungovernable 
irritability,  he  wanted  to  send  for  the  plumber  in  the  middle  ot  tin' 
night.  His  wife  persuaded  him  to  consult  a  homoeopathic  physician,  by 


156  DISEASES   OF    THE    CEREBRUM    AND    CEREBELLUM. 

whom  he  was  treated  for  nearly  a  year,  and  at  the  end  of  that  time 
went  abroad.  He  had  meanwhile  grown  much  worse,  his  mentiil  state 
was  much  more  aggravated,  and  his  headaches,  though  not  so  severe, 
were  still  constantly  present.  He  complained  of  formication  of  the  soles 
of  the  feet,  and  his  walk  was  markedly  affected,  both  feet  being  scarcely 
lifted  from  the  ground,  and  he  dragged  one  after  the  other  when  lie 
walked.  He  lost  rapidly  in  flesh,  and  though  the  sea-voyage  did  him  some 
good,  he  relapsed  into  his  previous  state  after  he  reached  Europe.  While  in 
Switzerland  he  had  an  epileptiform  attack,  and  after  recovery  found  that  his 
right  side  was  paralyzed.  His  speech  was  affected,  and  from  what  I  can  learn 
he  must  have  been  aphasic.  The  paralysis  improved  in  a  short  time,  and, 
strange  to  say,  his  mental  condition  also  underwent  a  change  for  the  better. 
After  a  few  months  he  returned  to  New  York,  when  I  saw  him. 

He  was  then  in  an  almost  helpless  condition,  and  needed  the  a^i-tance 
of  a  cane  and  his  nurse's  arm  to  make  any  progress.  He  was  bent  over. 
and  his  chin  was  depressed,  so  that  it  almost  touched  the  chest.  The 
mouth  was  open,  and  the  lower  lip  drooped  slightly ;  while  from  the  cor- 
ners of  the  mouth  there  was  an  escape  of  saliva  which  trickled  down  over 
his  chin.  His  face  bore  a  very  vacant  look,  and  when  he  attempted  to 
speak  it  was  clouded  by  an  anxious  and  discontented  expression,  which 
arose  probably  from  the  vexation  he  felt  at  being  unable  to  speak.  Pho- 
nation  was  not  affected,  but  word  formation  seemed  entirely  lost,  so  that 
his  attempts  to  speak  consisted  in  the  production  of  disorderly  noises,  the 
tongue  being  used  extensively,  the  lips  not  participating.  He  could  not 
protrude  his  tongue  when  told  to  do  so.  His  right  pupil  was  larger  than 
the  left.  His  right  side  was  partially  hemiplegic,  and  his  wife  stated 
that  the  loss  of  power  was  greater  at  times  than  at  others.  The  right  fore- 
arm was  slightly  flexed  upon  the  arm,  and  the  fingers  seemed  rigid.  His 
control  over  the  bladder  was  partially  lost,  and  very  often  he  would  void 
his  urine  while  upon  the  street,  orlvt  night.  There  is  a  history  of  trem- 
bling which  affects  the  right  arm  and  leg.  This  occurs  during  quiescence, 
and  seems  to  have  no  connection  with  voluntary  movements.  His  appe- 
tite is  voracious,  but  there  appears  to  be  some  difficulty  in  swallowing,  so 
that  it  is  found  necessary  to  cut  up  his  food.  About  two  weeks  ago  he  had 
a  slight  epileptoid  attack.  During  warm  days  he  seems  disposed  to  sleep 
a  great  deal ;  but  when  excited  by  the  presence  of  disagreeable  people,  or 
thwarted  or  crossed,  he  becomes  extremely  violent,  and  even  dangerous. 
I  saw  him  but  once,  and  I  believe  he  was  afterwards  sent  to  an  asylum. 

Causes — First  and  foremost  are  primary  forms  of  disease,  which  either 
produce  occlusion  of  an  artery,  or  irritation  from  a  blood-clot  or  tumor. 
Vascular  degeneration,  which  may  result  from  general  disease,  or  renal 
trouble,  acts  as  a  predisposing  cause  in  the  development  of  cerebral  soften- 
ing. Intellectual  fatigue,  sexual  excitement,  alcoholic  intoxication,  head 
injuries,  and  local  disease  act  as  exciting  causes.  Exposure  to  cold  has 
been  given  as  a  cause  of  cerebral  softening,  and  exposure  to  the  direct  rays 
of  the  sun  may  induce  the  condition.  Bamberger1  has  observed  it  as  a 
consequence  of  typhus  and  acute  articular  rheumatism  ;  and  Jaccoud"  con- 

1  Beobachtungen  und  Bcrnerkungen  liber  Hirnkrankheiten  (Wlirzburg  Ver- 
handlungen,  185C). 

2  Pathologic  Interne,  torn.  i.  p.  177. 


CHRONIC    SOFTENING.  15f 

aiders  that  it  may  be  produced  by  syphilis  in  two  different  ways,  either  by 
a  gummy  tumor,  which  gives  rise  to  irritation  of  the  tissue  in  the  neigh- 
borhood, or  by  infiltration. 

Cerebral  softening  is  more  common  among  people  of  advanced  life  as  an 
idiopathic  affection,  and  unless  it  follows  embolism  injuries,  or  like  causes, 
is  quite  rare  in  early  life,  Andral  having  found  only  39  cases  out  of  153 
in  persons  under  40.  Jaccoud  is  of  the  opinion,  which  others  hold,  that 
males  are  more  commonly  affected  than  females.  Season  has  nothing  to 
do  with  its  development. 

1  Morbid  Anatomy  and  Pathology There  has  been  great  dif- 
ference of  opinion  in  regard  to  the  pathology  of  brain  softening.  Those 
who  described  it  in  the  early  part  of  the  century  considered  it  to  be  an  in- 
flammatory affection,  while  Rostan,1  who  reported  many  cases,  recognized 
a  non-inflammatory  form  which  he  had  met  with  among  old  people  with 
rigid  arteries.  As  Russell  Reynolds2  very  properly  observes,  "  much  con- 
fusion has  arisen  from  a  tendency  to  misinterpret  morbid  anatomical  ap- 
pearances, without  paying  sufficient  attention  to  their  mode  of  origin." 
Cruveilhier3  considered  two  forms,  one  of  which  was  apoplectic,  or  "  apo- 
plexie  capillaire."  which  he  did  not  consider  inflammatory  :  and,  later, 
Andral4  announced  his  disbelief  in  the  necessarily  inflammatory  origin  of 
the  disease,  and  considered  it  due  to  occluded  arteries  and  insufficient 
nutrition.  Among  the  powerful  advocates  of  the  inflammation  theory  are 
Durand-Fardel5  and  Gluge,6  while  upon  the  other  side  may  be  mentioned 
such  additional  names  as  Kirkes,7  Laborde,8  Hughlings  Jackson,9  and 
many  others.  It  may  be  said,  I  think,  that  softening  of  the  brain  is  nearly 
always  of  an  inflammatory  character  when  it  follows  head  injury  and  dis- 
eases of  the  cranial  bone,  while  the  majority  of  cases,  which  are  secondary 
to  occlusion  of  vessels,  are  dependent  upon  general  disease  of  a  non-inflam- 
matory nature. 

If  the  disease  be  primary,  Jaccoud  considers  that  the  lesion  will  be  of 
the  first  form,  that  is,  at  a  single  point ;  but  that  when  the  softening  follows 
typhus  fever,  puerperal,  and  other  general  diseases,  the  foyers  will  be  mul- 
tiple. If  the  softening  results  from  embolism  or  thrombosis,  or,  in  fact, 
from  any  other  condition  producing  obstruction  of  the  circulation,  there 
will  first  be  a  congestion  with  exudation  of  serum,  hyperaemia  of  the  vessels, 
and  perhaps  capillary  hemorrhage,  which  is  attended  by  coloration  of  the 
parts  in  the  neighborhood,  so  that  they  become  of  a  bright  pink  or  red 
color,  and  are  limited  by  other  regions,  which  are  anaemic  and  blanched, 
and  a  condition  which  has  been  called  "  red  softening"  exists.  If  this 
morbid  process  takes  place  in  the  grp-y  matter,  the  hemorrhagic  spot  will 
be  of  a  much  darker  color,  and  much  more  sharply  circumscribed.  The 

1  Recherches  siir  le  Ramollissement  du  Cerveau,  1820. 
-  System  of  Medicine,  vol.  ii.  p.  461.        3  Etude  de  la  M6d.,  etc.,  1821. 
4  Precis  d'Anatomie  Path.,  1829.  5  TraitS  du  Ramollissement,  1843. 

6  Comptes  Rendus,  1837.  '  Op.  cit.,  vol.  xxxv.  p.  821. 

8  Le  Ram.  et  la  Cong,  du  Cerveau,  Paris,  1859. 

9  Op.  cit. 


158  DISEASES   OF    THE    CEREBRUM    AND    CEREBELLUM. 

next  change  takes  place  within  a  week  or  two,  when  the  color  of  the 
becomes  much  more  pale,  ami  the  exudation  granular;  fatty  degeneration 
takes  place,  the  softened  spot  becomes  extended,  the  neuroglia-cells,  ncrvc- 
h'bres,  and  nerve-cells  become  disintegrated,  the  axis  cylinders  disappear. 

Fig.  1C. 

DIAGRAMMATIC. 


TISSUE  CHAXGES  IN  SoFTEXiso.    A.  Vessel.     B,  B,  C.  Nerve-tubes.     D.  Gluge's  corpuscles. 

E.  Swollen  nerve-tube. 

and  the  bloodvessels  alone  may  be  distinguished,  and  even  they  are  greatly 
disorganized.  At  this  stage  the  softened  spot  becomes  much  paler,  is 
creamy  in  consistence,  and  contains  stringy  flakes  of  a  fibrinous  nature. 
It  is  extremely  rare  for  resolution  to  take  place  even  in  the  earliest  stage. 
A  form  of  softening,  alluded  to  by  Jaccoud,  Durand-Fardel,  and  others, 
consists  in  the  formation  of  yellow  plates,  chiefly  in  the  convolutions 
(plaques  jaunes)  which  are  the  result  of  a  partial  metamorphosis  of  the 
softened  patches.  There  may  be  also  a  retrograde  change,  as  is  witnessed 
in  the  formation  of  cysts,  which  are  filled  by  a  chalky  fluid  containing  fat 
globules.  There  is  always  present  a  variety  of  cells  known  as  Gluge's 
globules,  which  are  composed  of  collections  of  small  granular  bodies,  some- 
times surrounded  by  a  cell  wall,  and  these  are  produced  by  the  degenera- 
tion of  neurojrlia-cells,  the  debris  of  which  are  aggregated  as  masses  of  fatty 
granules.  These  little  bodies,  which  rarely  exceed  5JV  of  an  inch  in 
diameter,  have  been  found  by  Reynolds,  Turck,  and  Bouchard  in  the  cord, 
where  their  form  of  origin  is  the  same. 

The  various  colors  may  be  seen  in  the  brain  at  the  same  time,  patches 
of  red,  brown,  yellow,  or  white  denoting  different  stages  of  the  morbid 
process.  The  lighter  shades  generally  indicate  advanced  stages,  such 
being  the  opinion  of  Durand-Fardel.  Charcot  and  various  observers  have 
found  forms  of  white  softening  in  old  people ;  and  others,  among  them 
Cotard,  Pre"  vost,  Bastian.  and  Reynolds,  have  seen  cases  of  the  same  kind. 
It  is  extremely  doubtful  whether  the  condition  of  degeneration  was  not 


CHRONIC    SOFTENING.  159 

preceded  by  some  exudation  of  blood-elements,  and,  if  it  was  not,  whether 
the  condition  had  not  been  confounded  with  sclerosis.  Softened  patches 
may  be  in  the  second  stage  removed  by  allowing  a  stream  of  water  to  fall 
upon  the  cut  surface,  and  when  the  disorganized  tissue  is  washed  away  a 
depression  is  left.  If  the  cut  be  made  through  a  brain  which  presents  the 
appearance  of  red  softening,  the  affected  patch  will  be  found  to  stand 
slightly  above  the  normal  tissue,  and  this  is  probably  due  to  a  hypersemia 
of  the  capillaries  of  the  part.  This  fulness  of  the  capillaries  is  undoubtedly 
due  to  collateral  circulation  of  blood  through  the  vessels  contiguous  to  that 
obliterated,  the  normal  functions  being  increased  through  double  duty 
imposed  upon  them.  This  is  the  view  held  by  Weber,1  as  well  as  by  Prdvost 
and  Cotard.2 

If  the  yellow  appearance  of  the  softened  patches  be  not  due  to  altered 
coloring  matter  of  the  blood  such  as  we  find  in  the  early  stages,  it  may  be 
found  later  in  connection  with  gelatinous  circumscribed  masses  scattered 
through  the  brain  or  about  old  clots  or  tumors. 

The  parts  most  liable  to  this  change  are  the  corpora  striata,  optic  thalami, 
white  substance  of  the  hemispheres,  and  sometimes  the  cerebellum ;  or 
there  may  be  multiple  foyers  scattered  through  different  parts  of  the 
brain. 

Durand-Fardel3  has  collected  sixty-two  cases  from  the  writings  of  other 
authors,  in  which  the  locality  of  the  softening  was  the  following : — 

Convolutions  and  white  substance          .         .-        .         .         .         .22 

Convolutions  alone        .........       6 

White  substance  alone  .         .         .         .          .         .         .         .5 

Corpus  striatum  and  optic  thalamus       ......       6 

Corpus  striatum  alone  .         .         .         .         .  .         .11 

Optic  thalamus  alone    .........       4 

Pons  Varolii         .         .         .         .         .         .         .         .  .3 

Cms  cerebri          .    ,     .         .  .         .         .         .         .         .1 

Corpus  callosum  .........       1 

Walls  of  the  ventricles  (septum)  ......       1 

Fornix          ...........       1 

Cerebellum  ............       1 

Diagnosis — In  an  excellent  lecture  delivered  by  Hughlings  Jackson,4 
he  says  :  "  I  do  not  see  how  the  diagnosis  that  there  is  actual  softening  of  the 
brain  is  in  any  case  to  be  possibly  arrived  at,  tinless  the  patient  has  certain 
local  paralytic  symptoms,  as  hemipleyia,  or  some  other  symptoms  imply- 
ing a  local  cerebral  lesion,  such  as  affection  of  speech;  or,  again,  unless 
there  be  signs  of  cerebral  tumor  (severe  headache,  urgent  vomiting,  and 
double  optic  neuritis)  or  evidence  of  injury  to  the  head.  For,  so  far  as  I 
know,  cerebral  softening  is  always  local ;  I  know  nothing  of  general  or 
universal  softening  of  the  brain.  To  be  warranted  in  diagnosing  soften- 

1  Handbuch  der  Allgem.  und  Spec.  Chirur.,  1865. 

2  Gaz.  Med.  de  Paris,  Mai  19,  1866,  p.  336. 

3  Op.  cit.  4  London  Lancet,  Sept.  4,  1875 


160  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

ing,  you  must  have  symptoms  which  point  to  local  disease.  I  do  not  say 
that  local  cerebral  softening  cannot  exist  without  localizing  symptoms.  I 
only  say  that  in  their  absence  you  are  not  warranted  in  diagnosing  its 
existence."  This  remark  is  made  in  connection  with  the  lecturer's  disbe- 
lief in  various  forms  of  functional  disease  which  are  so  often  improperly 
called  "softening,"  and  in  which  a  few  functional  symptoms  which  disap- 
pear under  appropriate  treatment  are  vested  by  the  careless  or  unscrupu- 
lous practitioner  with  an  importance  they  do  not  deserve.  These  symptoms 
are  those  which  follow  depraved  states  dependent  upon  venereal  excesses, 
fright,  and  other  causes  which  lower  the  tone  of  the  nervous  system. 
Jackson's  warning  is  a  pertinent  one. 

If  we  have  hemiplegia,  some  renal  or  cardiac  disease,  and  valvular  de- 
posits, with  murmurs,  our  suspicions  of  softening  generally  turn  out  to  be 
well  founded.  The  history  of  the  antecedent  attack,  should  it  be  throm- 
bosis, embolism,  or  cerebral  hemorrhage,  has  much  to  do  with  the  making 
of  a  correct  diagnosis.  As  I  have  said,  hemiplegia,  unattended  by  loss  of 
consciousness  at  the  outset,  is  a  diagnostic  point  in  favor  of  softening,  and 
suggests  embolism,  and  if  the  train  of  symptoms  given  on  a  previous  pain- 
is  afterwards  expressed,  there  can  be  little  doubt  as  to  the  nature  of  the 
disease.  A  point  insisted  upon  by  Jackson  is  that  the  general  mental 
symptoms  of  softening  are  either  expressed  before  the  softening,  or  follow 
it.  He  denies  that  general  mental  symptoms  (wandering,  delusions,  etc.) 
are  directly  caused  by  the  softening,  but  that  special  mental  symptoms 
(affection  of  speech)  are.  The  general  mental  symptoms  follow  a  few 
hours  or  days  after  the  local  softening.  The  "preceding  mental  symp- 
toms "  are  irritability  and  altered  disposition. 

Chronic  meningitis  may  resemble  cerebral  softening,  but  in  the  former 
the  pain  is  more  diffused,  and  the  motorial  phenomena  (spasms,  etc.)  are 
more  pronounced.  Softening  with  tumor  niay  be  made  out  from  the  addi- 
tional presence  of  optic  neuritis,  choked  disk,  and  Vomiting.  Some  forms 
of  progressive  meningitis,  such  as  pachymeningitis  with  cerebral  h;ematoma 
(vide  the  case  detailed  in  the  chapter  upon  pachymeningitis),  may  closely 
simulate  cerebral  softening,  and  very  often  the  diagnosis  is  exceedingly 
ditlicult,  or  may  be  impossible.  The  symptoms  of  hemorrhage  from  rup- 
ture of  a  meningeal  vessel,  such  as  occurs  in  the  course  of  these  chronic 
varieties  of  meningitis,  may  closely  counterfeit  the  apoplectic  attack  which 
occurs  so  often  in  cerebral  softening. 

Prognosis. — Cerebral  softening  is  one  of  the  most  unfavorable  con- 
ditions with  which  we  are  acquainted.  Death  follows  the  establishment 
of  the  morbid  condition  sooner  or  later  in  nearly  all  cases  occurring  in 
adult  life.  An  occasional  case  of  recovery  may  be  encountered  in  a  young 
subject,  but  this  is  exceptional.  Of  109  cases  of  both  forms  of  cerebritis 
collected  by  Aitkin,1  he  found  that  the  duration  of  life  in  cases  of  this 
disease  was  the  following,  which  also  proves  that  there  are  more  cases  of 
the  acute  than  the  chronic  form  of  the  disease. 


1  The  Science  and  Practice  of  Medicine,  vol.  ii.  p.  304. 


APHASIA.  161 

1  died  in  12  hours.  2  died  in  12  days.  1  died  in  35  days. 

1  "  "  15  "  3  "  "  13  "  1  "  "  36     " 

1  "  "  24  "  3  "  "  15  "  1  "  "  47     " 

1  "  "  32  "  1  "  "  16  "  1  "  "  49     " 

5  "  "     2  days.  2  "  "  17  "  1  "  "  60     " 

9  "  "     3  "  4  "  "  18-  "  1  "  "  65     " 

5  "  "     4  "  5  "  "  20  "  1  "  "  68     " 

4  "  "     5  "  3  "  "  21  "  1  "  "  190     " 

7  "  "     6  "  1  "  "  22  "  1  "  "  220     " 

8  "  "     7  "  1  "  "  23  "  1  "  "      5  months. 
8  "  "     8  "  1  "  "  25  "  2  "  "      6     " 

3  "  "     9  "  1  "  "  29  "  1  "  "       1  year. 

5  "  "  10  "  4  "  "  30  "  2  "  "      3  years. 

4  "  "   11  " 

The  greater  number  of  these  patients  died,  it  will  be  seen,  before  the 
twelfth  day. 

The  experience  of  other  observers  is  slightly  different  from  this,  as  many 
persons  with  secondary  softening  have  been  found  to  live  for  years  after 
the  commencement  of  the  softening.  These  cases  being  all  fatal  we  have 
to  remember  as  well  that  there  are  many  instances  in  which  the  abscess 
becomes  encysted,  or  the  non-inflammatory  softening  circumscribed. 

Treatment — Our  efforts  should  be  to  improve,  as  rapidly  and  fully 
as  possible,  the  patient's  general  condition.  For  this  purpose  we  must 
not  only  prescribe  for  him  a  hearty  hydrocarbonaceous  diet,  but  we  are  to 
insist  upon  cold  bathing,  out-door  exercise,  and  moderate  stimulation. 
As  medicaments,  I  am  positive  that  there  is  no  better  remedy  than  phos- 
phorus, which  may  be  given  in  combination  with  cod-liver  oil,  or  in  solu- 
tion in  absolute  alcohol  (FF.  37,  24,  25,  26).  The  bromides  may  be 
given  in  combination  with  lupulin  (F.  38),  if  there  be  headache  or  de- 
lirium; or  cannabis  indica,  as  recommended  by  Reynolds  (F.  39).  If 
the  bowels  be  sluggish,  a  free  use  of  the  saline  cathartics  is  of  great  bene- 
fit; and  to  relieve  the  head  symptoms,  leeching  may  do  much  good.  In 
the  chronic  form  tonics  are  indicated,  and  for  this  purpose  I  prefer  the 
ammonio-citrate  of  iron  (F.  40).  I  am  not  in  favor  of  strychnine,  and 
should  hesitate  to  use  it  if  the  case  were  at  all  acute. 

ASEMASIA1  (APHASIA). 

Synonyms — Aphemia,  Alalia,  Laloplegia,  Paralalie,  Agraphia. 
Definition We  may  define  asynesis,  or  aphasia  (which  is  derived 

1  It  has  occurred  to  me  that  the  word  "aphasia,"  as  at  present  used,  has  too 
restricted  a  meaning  to  express  the  various  forms  of  trouble  of  this  nature,  which 
not  only  consist  of  speech  defects,  but  loss  of  gesticulating  power,  singing,  read- 
ing, writing,  and  other  functions  by  which  the  individual  is  enabled  to  put  him- 
self in  communication  with  his  fellows.  I  would,  therefore,  suggest  "asemasia" 
as  a  substitute  for  "aphasia."  The  word  is  derived  from  d  and  u^cwVw  (an 
inability  to  indicate  by  signs  or  language)- 
"ll 


162  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 


from  the  Greek  o,  priv.,  and  $d<jij,  speech)  as  a  partial  or  complete  loss 
of  speech,  which  does  not  depend  upon  any  vocal  or  lingual  impairment 
of  function,  but  upon  disease  of  the  speech-centre,  whereby  the  origina- 
tion of  forms  of  expression  is  suspended  or  deranged  to  a  greater  or  less 
degree,  or  a  kindred  loss  of  writing  or  gesticulating  power.  Aphasia 
must  not  be  confounded  with  aphonia,  or  with  the  condition  met  with  in 
idiots  or  mutes.  The  disease  we  are  about  to  consider  is  seated,  as  it  is 
generally  conceded,  in  the  third  frontal  convolution,  and  is  characterized 
by  the  disruption  of  the  connection  between  the  formation  of  ideas  and 
their  expression  by  the  lingual  apparatus;  or,  as  Broca  has  expressed  it: 
"  Le  mot  aphasie  sert  aujourd'hui  a  designer  la  perte  ou  la  perversion  de 
la  faculte  du  langage  ;  en  generate  c'est  de  cette  faculte"  que  nous  permet 
d'&ablir  une  relation  constante  entre  une  ide*e  et  un  signe,  que  ce  signe 
soit  un  mot,  un  geste,  ou  un  trace  quelconque."  This  loss  of  function  varies 
from  temporary  trouble,  such  as  the  substitution  of  an  occasional  wrong 
word,  to  a  condition  of  decided  intellectual  abasement.  It  will  be  well, 
before  discussing  the  subject  further,  to  say  a  few  words  in  regard  to  the 
history  of  this  interesting  disease.  Our  first  information  comes  from  very 
early  writers,  among  whom  were  Sextus  Empiricus,1  who  lived  two  hun- 
dred years  before  Christ,  and  Pliny.  Trousseau  (p.  253)  quotes  the  latter: 
"•Illness,  falls,  a  mere  fright,  impair  it  (memory)  partially,  or  destroy  it 
completely.  A  man  struck  by  a  stone  forgot  the  letters  of  the  alphabet," 
etc.  Later,  Sauvage,2  Cullen,3  and  the  two  Franks4  wrote  most  ex- 
haustively during  the  seventeenth  and  eighteenth  centuries,  but  all  of 
these  authors  devoted  more  attention  to  mutism,  aphonia,  and  like  condi- 
tions, than  to  aphasia.  In  1840,  Lordat,5  who,  strange  to  say,  bee:  une 
aphasie  himself,  described  the  disease  under  the  name  of  alalia,  a  term 
used  by  Jaccoud  at  the  present  day.  Though  Gall,6  as  early  as  1808, 
localized  the  speech-centre  above  the  orbits,  it  was  not  till  1825  that  its 
pathology  and  morbid  anatomy  were  clearly  settled  by  Bouillaud,7  who, 
working  upon  Gall's  theory,  enunciated  the  doctrine  that  "  the  anterior 
lobes  of  the  brain  are  the  organs  for  the  formation  and  recollection  of 
words,  or  the  principal  signs  which  represent  our  ideas." 

Afterwards,  Bouillaud's  views  were  nevertheless  opposed  by  Andral,8  Cru- 
veilhier,9  and  others,  to  whom  I  shall  hereafter  allude.  Experiments  made 
by  Marce  in  1850,  and  by  others,  confirmed  all  that  Bouillaud  had  stated. 


1  Translated  by  Huart,  Amsterdam,  1725,  p.  93. 

2  Xosologia  Meth.,  Paris,  1722,  t.  ii.,  class  6,  p.  249. 

3  Synopsis  Nosolojrite  Metli.,  edited  by  Frank,  1787. 

4  De  Curandis  Horn.,  Mannheim  et  Vienna,  1792-1821. 

s  Analyse  de  la  parole  pour  servir  &  la  thSorie  du  divers  cas  d'alalie  et  de  para- 
lalie.  etc.,  Montpellier,  1843. 

6  Sur  les  Fonctions  du  Cerveau,  Paris,  1825,  t.  v. 

7  Treatise  on  Encephalitis,  p.  284. 

8  Maladies  de  1'Encephale  (Clin.  M6d.,  1834,  t.  ii.). 

9  Sur  le  priucipe  16gislateur  de  la  parole  (Bull,  de  l'Acad6mie,  1839). 


APHASIA.  163 

The  next  step  was  taken  by  Marc.Dax1  in  1836,  and  by  his  son,  who  con- 
firmed his  observations  in  1863.  It  was  the  younger  Dax  who  demon- 
strated that  aphasia  was  connected  with  right-sided  paralysis.2  Broca3 
next  limited  the  spot  to  the  second  or  third  frontal  convolution.  Since 
then  Hughlings  Jackson,4  Jaccoud,8  Trousseau,8  Dieulafoy,7  Gairdner,8 
and  many  others  have  added  much  to  the  interest  of  the  subject.  There 
has  been  considerable  discussion  as  to  the  proper  name  for  the  affection. 
Lordat,  to  whom  1  have  already  alluded,  preferred  the  term  "alalia;" 
and  others,  among  them  Broca,  denominated  the  condition  "apkemia" 
The  word  is  still  used  by  some  writers;  but  the  word  "aphasia"  has 
come  into  general  use,  and  is  generally  conceded  to  be  much  more  expres- 
sive and  proper  than  any  other. 

Jaccoud,  who  has  rather  added  to  the  confusing  nomenclature,  presents 
a  table,  which  embodies  nothing  new,  and,  if  anything,  increases  the  in- 
definiteness  of  our  knowledge  of  the  disease.  Aphasia,  or  asemasia,  is 
most  protean,  as  it  may  involve  the  power  of  reading  aloud,  speaking, 
writing,  and  gesticulating,  in  part  or  together,  in  a  number  of  curious 
ways.  Let  us  then  consider  the  phenomena  which  mark  its  existence. 

Speech. — The  vocabulary  of  the  aphasic  patient  is  generally  of  the  most 
limited  kind,  and  in  the  beginning,  should  the  condition  follow  a  cerebral 
accident  of  any  magnitude,  his  power  of  speech  is  totally  absent.  After  a 
while  he  may  be  able  to  command  one  or  two  short  phrases,  or  such  words 
as  "  yes"  or  "  no"  in  reply  to  every  question  that  may  be  asked.  These 
words,  or  such  as  have  become  automatic  from  constant  use,  are  employed, 
and  it  is  very  curious  sometimes  to  hear  the  patient  give  utterance  to  some 
phrase  which,  during  health,  he  has  constantly  and  sometimes  uncon- 
sciously made  use  of.  In  other  instances  several  words  may  be  joined 
together  in  an  incongruous  manner ;  for  example,  it  was  observed,  in  a 
ease  I  detailed  when  speaking  of  cerebral  thrombosis,  that  the  patient  replied 
"  When  Benny"  to  the  question  "  where  do  you  live?"9  Durand-Fardel 

1  Lesions  de  la  moiti6  gauche  de  1'encephale  coincident  avec  Poubli  des  signes 
de  la  pens6e.     Mem.  lu  an  Congres  Medicale  de  Montpellier,  1836 — Gaz.  Heb. 
Avril,  1865. 

2  Sur  le  sifege  de  la  faculte  du  langage,  etc.  (Bull,  de  la  Soc.  Anat.,  2e  S6rie, 
t.  iv.  1861). 

3  Gaz.  Heb.,  April  28,  1865. 

4  Rep.  London  Hospital,  vol.  i.  1864,  p.  388. 

5  Gaz.  Heb.,  July  and  Aug.  1864. 

6  Clin.  Med.  de  1'Hdtel  Dieu,  t.  ii.  p.  571. 

7  Gaz.  des  Hop.,  June,  1865. 

8  Arch,  de  Med.,  t.  ii.  pp.  189-314,  1869.     The  reader  is  referred  to  the  ad- 
mirable thesis  of  Legroux,  Paris,  1875  (A.  Delahaye),  for  a  most  complete  bib- 
liography of  the  subject. 

9  Numerous  interesting  cases  are  reported.     One  described  by  Osborn*  is  illus- 
trative of  a  form  which  is  sometimes  met  with.     The  patient  comprehended  written 
language,  and  expressed  himself  in  writing,  only  occasionally  transposing  words. 

*  Forbes  Winslow,  Obscure  Diseases  of  the  Mind.  p.  343. 


164  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

alludes  to  a  patient  who  always  gare  the  following  absurd  answer : 
"  Madame  &£,  mon  Dieu,  est-il  possible,  bon  jour,  madame."  Legroux1 
remarks  in  regard  to  these  forms :  "  It  is  to  be  supposed  in  these  cases 
that  the  patients  speak  without  hearing  what  they  say,  or  that  their  audi- 
tory receptivity  is  unable  to  reveal  the  imperfection  of  their  speech." 
Occasionally,  however,  the  aphasic  is  conscious  of  the  absurdity  of  his 
reply ;  he  will  laugh  in  a  silly  manner,  or  appear  annoyed  or  worried,  for, 
in  a  majority  of  cases,  there  is  perfect  mental  integrity,  and  the  position 
of  the  patient  is  very  like  that  of  a  man  driving  a  runaway  horse.  It  1ms 
often  reminded  me  of  a  condition  which  I  have  more  than  once  expe- 
rienced myself,  and  which  is  by  no  means  uncommon.  I  allude  to 
the  state  of  the  mind  during  nightmare.  When  the  individual  is  about 
to  awake  he  is  semi-conscious  of  the  unsubstantial  character  of  the  im- 
pending danger  of  the  dream,  but  cannot  save  himself  and  cannot  awake. 
During  the  nightmare  a  patient  may  actually  spring  from  the  bed,  or 
make  some  other  voluntary  attempt  to  escape.  Lordat,  who  was  aphasic, 
gave,  after  his  recovery,  an  account  of  the  inward  sensations  which  he  felt 
during  his  illness,  and  which  perfectly  indicate  the  part  played  by  memory. 
He  could  think,  he  could  coordinate  a  lecture,  or  change  its  arrangement 
in  his  own  mind,  but  he  was  unable,  although  he  was  not  paralyzed,  to 
express  his  thoughts  in  speaking  or  writing.  "  I  thought,"  said  he,  "  of 
the  Christian  doxology,  '  Glory  be  to  the  Father,  the  Son,  and  the  Holy 
Ghost,'  and  I  was  not  able  to  recollect  a  single  word  of  it.  Thoughts 
seemed  to  arise  freely,  but  the  mode  of  expressing  them  in  sounds,  the 
receptacle  of  these  thoughts,  was  forgotten."2  The  words  which  are  gene- 
rally lost,  and  are  the  latest  to  be  acquired,  are  the  pronouns  and  'substan- 
tives, while  those  which  the  individual  retains  the  power  of  articulating 
more  than  any  other  are  the  interjections,  such  as  "  Oh  !"  "oh,  dear!"  "ah, 
yes !"  It  is  not  rare  for  patients  to  exhibit  two  other  peculiarities  ;  one  is 
a  substitution  of  other  words  for  those  intended,  the  second  is  a  conjunc- 
tion of  incongruous  syllables ;  for  instance,  a  patient  may  say  "  bel-eb" 
for  "  belief,"  or,  as  in  the  case  reported  by  Trousseau,  "  bon-tif "  was  sub- 
stituted for  "  bonsoir."  Some  persons  are  able  to  repeat  words  which  are 
first  pronounced  for  them  by  another,  but  are  unable  a  minute  afterwards 

He  could  translate  fluently,  and  was  able  to  calculate  arithmetical  sums.  He 
could  not  pronounce  the  letters  "  £,  y,  w,  v,  «?,  x,  and  z,"  and  the  letter  "  t" 
seemed  to  puzzle  him.  Dr.  Osborn  requested  him  to  read  the  following  sentence 
from  the  By- Laws  of  the  College  of  Physicians  :  "It  shall  be  in  the  power  of  the 
college  to  examine  or  not  any  licentiate  previous  to  his  admission  to  a  fellowship, 
as  they  shall  think  fit."  The  result  was  as  follows:  "An  the  bi  what  in  the 
temother  of  the  tro  tho  todoo  to  majorum  or  that  emidrate  ein  einkrastrai  mes- 
treit  toketra  to  torn  breidei  to  ra  fromtreido  as  that  kekritest."  It  is  rare,  how- 
ever, for  a  patient  to  accomplish  as  much  as  this.  He  generally  becomes  im- 
patient, and  gives  up  the  attempt  after  half  a  dozen  imperfect  words. 

1  De  1'Aphasie,  p.  15. 

2  Trousseau's  Lectures  on  Clinical  Medicine,  vol.  ii.  p.  273,  last  Am.  edition, 
1873. 


APHASIA.  165 

to  .articulate  the  desired  word.  A  patient  of  my  own,  when  requested  to 
tell  what  it  was  he  held  in  his  hand,  could  not  say.  When  asked  if  it  was 
a  paper,  he  shook  his  head  ;  an  apple  ?  another  shake,  and  a  shrug  of  the 
shoulder  ;  a  cane  ?  a  pitying  smile,  and  a  gesture  of  impatience  ;  a  book  ? 
a  bright  smile,  and  the  immediate  articulation  of  the  word  "book." 
••What  did  you  say  it  was?"  To  which  there  was  a  puzzled  look,  an 
attempt  to  speak,  and  no  answer.  Jackson  and  others  have  alluded  to 
striking  examples  of  this  defect.  Bastian1  alludes  to  a  form  in  which 
there  was  transposition  of  the  letters,  the  patient  saying  "gum"  for 
"  mug."  Patients  are  very  apt  to  substitute  words.  Thus,  when  one 
was  asked  if  he  wanted  to  sit  down,  replied :  "  Give  me  a  bottle,  1 
want  to  rise  down."  Bauduy9  alludes  to  a  case  where  the  connection  was 
better  shown.  The  man  asked  for  a  "  cup  of  cow /"  Some  aphasics, 
though  they  may  be  utterly  unable  to  speak,  can  sing.  Hughlings  Jack- 
son3 alludes  to  two  aphasics,  boys,  one  eight  and  the  other  ten,  who  could 
sing.  Bacon  reported  the  case  of  an  idiot  boy  who  was  aphasic,  but  could 
sing  quite  cleverly.  These  cases  are  very  rare,  but  interesting  examples 
are  occasionally  brought  forward.  Behier  reports  the  case  of  a  sailor  who 
could  sing  the  Marseillaise,  using  the  word  "  tan"  throughout. 

Writing — The  aphasic  individual  who  cannot  speak  is  occasionally 
able  to  write,  but,  in  my  experience,  I  have  generally  found  the  loss  of 
these  faculties  (speech  and  writing  power)  to  coexist.  This  variety, 
which  has  been  called  agraphia  by  Ogle,  has  been  divided  by  him  into 
the  anemonemic  and  atactic  varieties.  We  may  meet  with  the  same 
peculiarities  which  attend  the  form  I  have  already  alluded  to,  viz. :  sub- 
stitution of  words  or  letters.  The  patient  may  be  able  to  write  after  a 
copy,  but  this  is  rare.  He  takes  his  pen  and  begins  quite  confidently,  but 
as  soon  as  the  pen  touches  the  paper  he  makes  a  series  of  scrawls,  which 
rarely  bear  any  resemblance  to  the  letters  forming  the  words  he  is  required 
to  write. 

Bourneville4  relates  a  case  :  "A  woman  named  Justine  Thomas  entered 
the  hospital  La  Pitie  December  15,  1870,  and  was  assigned  to  the  service 
of  Marotte.  She  became  hemiplegic  on  the  right  side,  and  had  complete 
aphasia.  On  the  18th  of  December  the  hemiplegia  had  nearly  disap- 
peared, but  the  aphasia  persisted.  At  this  time  she  was  asked  to  write 
her  name,  and  only  succeeded  in  producing  the  appearance  presented  in  the 
accompanying  cut  (Fig.  17,  A).  At  different  times  during  the  year  speci- 
mens of  her  handwriting  were  taken,  which  showed  progress  and  marked 
improvement,  the  last  attempt  being  made  in  November,  1871.  (Fig. 
17,  ./?.)  This  lost  power  must  not  be  confounded  with  other  conditions 
symptomatic  of  insanity  or  sclerosis  and  the  element  of  paralysis,  which 
should  be  taken  into  account  if  there  be  any  suspicion  of  a  loss  of  muscu- 
lar power.  A  hemiplegic  may  be  unable  to  write  simply  through  muscular 
weakness  and  difficult  muscular  coordination.  Of  course  time  will  ena- 

1  Med.-Chir.  Rev.,  xliii.  p.  209.          *  Diseases  of  Nervous  System,  p.  412. 
3  Lancet,  1871,  p.  430.  4  Legroux's  Thesis. 


16B  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM 

hie  us  to  see  whether  the  inability  to  writels  due  to  this  cause,  or  is  milly 
the  "agrophic"  condition.     Reading,  singing,  and  the  rower  oi  ges 

Fig.  17. 


B 


lating  are  lo<t  either  separately  or  together.     A  person  who  cannot  speak 
is  sometimes  ahle  to  sing.     So,  too,  in  reading.     He  may  read  mechani- 

Fig.  18. 


Handwriting  of  two  patientii:  "A"  being  affected  with  ugraphia,  and  "  B"  with  cerebro- 
j.in.il  »el<To»l».  The  flrit  specimen  is  iut«uded  for  "  Possible  to  see  you  on  Tuesday."  The 
«T  ind,  •'  Dieu  ot  mun  Droit." 


rally  without  appreciating  tlie  sense,  or  may  drop  his  words  or  substitute 
others,  and  |>erhaps  is  unconscious  of  his  mistake.  He  may  be  unable  to 
read,  but  may  show  by  signs  that  he  knows  what  such  and  such  a  picture 
may  be.  The  jx>wer  of  gesticulation  may  be,  and  often  is,  lost.  He  may 
make  attempts  to  describe  the  figure  of  some  object,  but  cannot  do  so. 
Trousseau  related  the  case  of  a  person  who  was  told  to  imitate  the  playing 
of  a  clarionet,  but  when  lie  attempted  to  do  so  beat  instead  an  imaginary 
tambourine.  He  is  sometimes  able  to  count  figures  which  are  before  him, 
or  piece*  of  money  put  in  his  hand,  but  if  he  has  no  such  reminders,  and 
is  simply  told  to  count,  he  may  be  able  to  count  up  to  a  certain  number, 
and  say  ten,  and  does  so  in  a  peculiarly  automatic  way.  After  this,  when 
some  thought  is  required  to  make  combinations,  the  effort  is  unsuccessful. 


APHASIA.  167 

For  the  purpose  of  making  himself  understood  it  is  necessary  that  an 
individual  should  be  familiar  with  signs  (visual  and  auditory),  which  have 
been  received  either  upon  the  retina  or  tympanum,  and  reflected  upon 
certain  ideational  and  receptive  centres,  where  they  are  retained  and 
serve  as  models  for  expressions  the  individual  may  wish  to  make  in  the 
future.  The  mental  process  which  attends  the  formation  of  language  or  the 
communicating  faculty  becomes  so  intricate  and  automatic  that  insensibly 
the  process  of  comparison  and  centre  stimulation  goes  on  without  the 
knowledge  of  the  person,  and  words  and  signs  are  made  upon  the  ground- 
work of  impressions  previously  received  for  guidance  and  formation.  It 
is  only  when  disease  affects  the  particular  centre  that  the  harmony  is  lost, 
and  the  patient,  though  possessing  the  ear  and  eye  as  mentors,  is  unable 
to  coordinate  the  mental  factors  of  intelligible  communication.  The  fa- 
cility for  connecting  ideas  with  sounds  or  signs,  which  is  a  normal  faculty, 
is  thus  spoken  of  by  Ogle  :  "  This  faculty  of  converting  ideas  into  symbols 
is  quite  distinct  from  that  of  converting  symbols  into  ideas.  The  one  may 
be  acquired  or  lost  independently  of  the  other.  Thus,  a  child  learns  to 
interpret  the  language  of  others  before  it  can  itself  speak.  Adults,  as  a 
rule,  follow  the  same  order  in  learning  a  new  or  foreign  language.  Most 
of  us,  moreover,  know  what  it  is  to  have  the  pictured  map  of  some  familiar 
object  in  our  minds,  yet  to  be  perfectly  unable  to  call  up  its  name."  This 
defect  depends  not  upon  the  apparatus  for  the  receipt  of  impressions,  nor 
upon  the  apparatus  for  communication,  but  upon  a  loss  of  function  in  what 
has  been  called  the  "central  organ  of  articulate  speech;  and  both  the  ina- 
bility to  remember  words  and  connect  them  with  ideas,  and  the  inability 
to  compel  the  organ  of  articulation  to  form  words,  depend  upon  some 
change  at  this  point.  The  loss  of  power  to  express  ideas  is  symptomatized 
by  aphasia,  agraphia,  or  other  defects  in  the  communicating  faculty.  If 
there  be  amnesia,  the  central  disturbance  (whatever  it  is)  is  the  same, 
and  the  variation  of  lost  means  for  expression  depends  on  the  manner 
of  separation  of  organs  from  mental  control.  There  seems  to  be  little 
doubt  as  to  the  seat  of  this  centre,  and  as  to  the  circumstances  under  which 
it  is  impaired.  The  collected  cases  of  different  authors  mainly  go  to  show 
that  the  left  side  of  the  brain  is  the  seat  of  a  lesion  in  its  anterior  part,  and 
that  the  third  frontal  convolution  is  the  one  most  constantly  involved.  I 
have  already  casually  referred  to  Broca's  investigations,  and  will  now 
present  his  description,  which  has  been  modified  by  Bateman,1  of  its  anato- 
mical seat.  "  The  anterior  lobes  of  the  brain  comprehend  all  that  part  of 
the  hemisphere  situated  above  the  fissure  of  Sylvius,  which  separates  it 
from  the  temporo-sphenoidal  lobe  and  in  front  of  the  furrow  of  Rolando 

(R.  R.)  which  separates  it  from  the  parietal  lobe The  direction  of 

this  furrow  is  almost  transverse  ;  setting  out  from  the  median  line,  it  con- 
tinues almost  in  a  direct  line,  and  after  describing  some  flexuosities  ter- 
minates below  and  outside  of  the  fissure  of  Sylvius,  which  it  meets  almost 
at  a  right  angle  behind  the  posterior  border  of  the  lobe  of  the  insula. 

1  Journal  of  Mental  Science. 


168  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

"  The  anterior  lobe  of  the  brain  is  composed  of  two  divisions,  the  one 
inferior,  or  orbital,  formed  by  the  several  convolutions  called  orbital,  which 
lie  on  the  roof  of  the  orbit,  and  of  which  I  shall  not  have  to  speak  ;  the 
other,  superior,  situated  under  the  outer  wall  of  the  frontal  bone,  and  un»l< T 


Fijr.  19. 


the  most  anterior  portion  of  the  parietal.  This  superior  division  is  com- 
posed of  four  fundamental  convolutions  called,  properly  speaking,  the  fron- 
tal convolutions;  one  is  posterior,  the  others  are  anterior.  The  posterior, 
F  F,  slightly  tortuous  from  the  anterior  boundary  of  the  furrow  of  Rolando. 
It  is  therefore  almost  transverse,  and  ascends  from  without,  inwards,  from 
the  fissure  of  Sylvius  to  the  great  median  fissure,  which  receives  the  falx 
cerebri  of  the  brain.  This  is  why  it  (F  F)  is  described  indifferently  under 
the  name  frontal,  posterior,  transverse,  or  ascending  convolution.  The 
other  three  convolutions  of  the  suj>erior  division  are  very  tortuous  and  very 
complicated,  and  some  practice  is  needed  to  distinguish  them  in  all  their 
length  without  confounding  the  fundamental  furrows  which  separate  them 
with  the  secondary  furrows  which  separate  the  second  order  folds,  and  which 
vary  in  different  individuals  according  to  the  degree  of  complication  ;  that 
is  to  say,  according  to  the  degree  of  development  of  the  fundamental  con- 
volutions. These  three  fundamental  convolutions,  1,2,  3,  are  antero-pos- 
terior,  and,  running  side  by  side,  extend  from  before  backward  over  the 
whole  length  of  the  frontal  lobe.  They  commence  on  a  level  with  the 
sujM-rciliary  arch,  whence  they  are  reflected,  to  be  continuous  with  convo- 
lutions of  the  inferior  division,  and  terminate  behind  in  the  frontal  trans- 
veree  convolution,  F,  F,  which  all  the  three  enter.  They  are  called  first 
(1),  second  (2),  and  third  (3),  frontal  convolutions.  They  may  also  be 
called  internal  (1),  middle  (2),  and  external  (3)  ;  but  the  ordinary  names 
have  prevailed.  The  first  (1)  runs  along  the  great  fissure  of  the  brain  ; 
it  presents,  constantly,  in  the  human  species  an  anterio-posterior  furrow 
more  or  less  complete,  which  divides  it  into  two  folds  of  a  second  order;  it 


APHASIA.  169 

has,  therefore,  been  divided  into  two  convolutions,  but  comparative  anatomy 
shows  that  these  two  folds  form  only  a  single  fundamental  convolution. 
The  second  (2)  i'rontal  convolution  presents  nothing  peculiar  ;  not  so  with 
the  third  (3),  which  is  more  external.  The  latter  presents  a  superior  or 
internal  border,  adjoining  the  tortuous  border  of  the  middle  convolution 
(2),  and  an  inferior  or  exterior  border,  the  relations  of  which  differ  accord- 
ing as  they  are  examined  before  or  behind.  In  its  anterior  half  this  bor- 
der is  in  contact  with  the  external  border  of  the  most  external  orbital  con- 
volution. In  its  posterior  half,  on  the  contrary,  it  is  free  and  separated 
from  the  temporal  sphenoidal  lobe  by  the  fissure  of  Sylvius,  S,  S,  of  which 
it  forms  the  superior  border.  It  is  in  consequence  of  this  latter  relation 
that  the  third  frontal  convolution  is  sometimes  called  the  superior  margi- 
nal convolution. 

"  Let  me  add,  that  the  inferior  border  of  the  fissure  of  Sylvius  (S,  S)  is 
formed  by  the  superior  convolution  of  the  temporo-sphenoidal  lobe,  which 
is  therefore  called  the  inferior  marginal  convolution  T,  T.  It  is  an  antero- 
posterior  fold,  thin,  and  almost  rectilinear,  which  is  separated  from  the 
temporo-sphenoidal  convolution  T  2,  T  2,  by  a  furrow  parallel  to  the  fis- 
sure of  Sylvius.  This  furrow  is  described  under  the  name  of  the  parallel 
fissure  (with  reference  to  the  fissure  of  Sylvius,  S,  S).  Lastly,  when  the 
two  marginal  convolutions,  superior,  3,  3,  3,  and  inferior,  T,  T,  are  drawn 
away  from  the  fissure  of  Sylvius,  S,  S,  there  appears  an  enlarged  and 
slightly  prominent  eminence,  I,  from  the  summit  of  which  five  small  sim- 
ple convolutions,  or  rather  five  straight  folds,  radiate  in  a  fan-like  manner. 
It  is  the  lobe  of  the  insula  which  covers  the  extra-ventricular  nucleus  of 
the  corpus  striatum,  and  which,  arising  from  the  bottom  of  the  fissure  of 
Sylvius,  S,  S,  is  found  to  be  structurally  continuous  by  its  cortical  layer 
with  the  deepest  or  most  deeply  seated  part  of  the  two  marginal  convolu- 
tions, 3,  3,  3,  and  T,  T,  and  by  its  medullary  layer  with  the  extra-ven- 
tricular layer  of  the  corpus  striatum.  The  result  of  these  structural  rela- 
tions is,  that  a  lesion  which  propagates  itself  continuously  from  the  frontal 
lobe  to  the  temporo-sphenoidal  lobe,  or,  vice  versa,  will  pass  almost 
necessarily  by  the  lobe  of  the  insula,  and  that  from  thence  it  will  most 
probably  extend  to  the  extra-- ventricular  nucleus  of  the  corpus  striatum, 
since  the  proper  substance  of  the  insula  I,  which  separates  the  nucleus 
from  the  surface  of  the  brain,  forms  only  a  very  thin  layer." 

Not  only  may  a  lesion  of  the  speech-centre  itself  produce  aphasia,  but 
in  numerous  instances  (some  of  which  have  been  referred  to  by  Jackson) 
it  may  follow  the  destruction  of  adjacent  parts,  as  a  consequence  of  some 
such  accident  as  the  plugging  up  of  the  middle  cerebral  artery.  As  a 
consequence  of  such  a  pathological  condition,  a  large  area  of  brain  sub- 
stance will  be  destroyed,  so  that  impaired  mental  function  as  well  as 
nphasia  takes  place. 

An  important  subject  in  this  connection  is  the  side  of  the  brain  which 
is  affected.  Though  exceptional  cases  have  been  reported  in  which  the 
right  cerebral  hemisphere  has  been  the  seat  of  the  lesion,  the  rule  is  the 
other  way.  In  some  instances,  even,  no  lesion  whatever  has  been  found ; 


170  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

or,  on  the  other  hand,  the  left  anterior  convolutions  have  been  the  seat  of 
morbid  change,  and  no  loss  of  speech  has  been  occasioned.  Simpson1  has 
related  one  case  where  marked  destruction  of  the  left  anterior  lobe  VMS 
observed,  and  yet  no  aphasia  existed.  This  man,  aged  65,  who  had  been 
epileptic  for  ten  years,  having  as  many  as  three  or  four  attacks  a  month. 
died.  The  white  and  gray  matter  of  the  left  hemisphere  were  markedly 
atrophied,  and  there  was  a  cavity  in  the  left  posterior  frontal  convolution 
1|  inches  longitudinally,  and  l£  transversely. 

The  following  case  is  interesting,  as  it  shows  that  almost  complete 
aphasia  may  exist  without  any  disease  of  the  island  of  Reil  : — 

M.  A.  B.,  aged  thirty-five  years,  married.  Family  and  previous  per- 
sonal history  good,  but  it  is  possible  to  trace  syphilis.  The  patient  had  an 
aj)oplectic  a'ttack  in  August,  1859,  with  loss  of  consciousness,  which  lasted 
for  two  hours  ;  on  recovery  it  was  found  that  she  was  unable  to  speak,  but 
there  was  slight  improvement  after  a  few  months.  Present  condition, 
July  17,  1874:  The  patient  is  a  medium-sized  woman  of  seemingly  good 
condition,  with  the  exception  of  her  nervous  trouble.  There  is  slight 
paralysis  of  the  left  side ;  can  move  left  arm  well,  but  slowly,  and  walks 
with  a  shuffling  gait.  Tactile  sensibility,  and  sensibility  to  differences  in 
temperature,  are  decidedly  impaired  on  the  left  side,  on  which  side  there  is 
an  appreciable  amount  of  analgesia.  She  protrudes  her  tongue  in  a  straight 
line,  but  feebly.  No  loss  of  taste  or  smell.  Her  mental  condition  is  be- 
low  the  average.  This  first  part  of  her  history  I  have  taken  from  the 
records  of  the  Epileptic  and  Paralytic  Hospital,  and  I  also  find  that  for 
some  months  she  has  been  suffering  from  symptoms  of  phthisis.  When  I 
saw  her  on  August  10,  1875,  the  patient  was  in  advanced  phthisis;  her 
nervous  condition  was  the  following  :  Paralysis  of  the  left  side  ;  her  left 
hand  lies  in  her  lap,  the  thumb  being  contracted  and  flexed ;  the  flexor 
tendons  of  the  hand  are  rigidly  contracted,  so  that  at  the  wrists  they  stand 
out  like  tense  cords.  There  is  very  little  atrophy  oT  the  left  upper  ex- 
tremity, but  there  is  a  certain  stiffness  about  the  elbow-joints  of  this  side. 
Tin-  left  lower  extremity  seems  to  be  nearly  as  strong  as  its  fellow.  Motion 
at  the  hip-  and  knee-joints  is  limited.  She  can  raise  her  foot  from  the  ground 
when  sitting,  but  when  she  walks  it  is  in  a  shambling  manner,  dragging 
her  left  foot,  or  scarcely  lifting  it  from  the  ground.  There  is  some  para- 
lysis of  the  left  side  of  the  face,  and  it  is  impossible  for  her  to  protrude  her 
tongue.  Sensibility  seems  to  be  very  slightly  affected  in  the  paralyzed 
side.  She  is  almost  completely  aphasic,  her  repertoire  of  words  being  con- 
fined to  "  yes"  and  "  no,"  the  former  being  repeated  several  times  in 
answer  to  any  questions  she  may  be  asked.  When  she  is  asked  her  name, 
she  is  unable  to  tell  it.  "  Is  it  Jane?"  she  shakes  her  head  and  smiles. 
"  N  it  Ann?"  another  shake  of  the  head,  and  an  attempt  to  speak,  the 
only  result  Ix-ing  the  production  of  an  unintelligible  noise.  ''  Is  it  Mary?" 

when   she  brightens  up  and  says,   "  Yes,  yes,  yes  ;  Ma "  prolonged, 

and  she  generally  gives  it  up  in  disgust.  She  cannot  write,  but  makes  a 
disorderly  scrawl ;  although  we  learn  from  her  friends  that  in  health  she 
wrote  well.  She  gesticulates  a  great  deal,  and  endeavors  to  attract  the 
attention  of  those  in  the  ward,  and  evidently  appreciates  everything  that 
goes  on  about  her.  Her  pupils  are  easily  dilated,  but  she  does  not  see 


Mod.  Times  and  Gazette,  Doc.  21,  1867. 


APHASIA.  171 

with  the  right  eye,  and  on  examination  I  find  atrophy  of  the  optic  disk. 
During  the  winter  and  spring  of  1875-76,  she  seemed  to  suffer  much  from 
her  pulmonary  trouble.  There  was  oedema  of  the  lower  extremities,  which 
increased  so  that  the  anasarca  became  general,  but  she  was  somewhat 
relieved  by  digitalis  and  iron ;  diarrhoea  supervened,  and  she  finally  died 
on  the  second  day  of  June,  1876. 

Autopsy — The  dura  mater  was  considerably  thickened,  and  presented 
the  appearance  of  old  pachymeningitis.  There  was  no  lesion  to  be  dis- 
covered in  either  third  frontal  convolution,  but  an  old  clot  was  found  in 
the  right  caudate  nucleus.  This  clot  was  about  half  an  inch  in  diameter, 
and  was  surrounded  by  some  dense  tissue.  Cortical  lesions  were  present 
on  both  sides  of  the  brain,  but  of  superficial  extent,  and  confined  chiefly  to 
the  parietal  convolutions ;  these  consisted  of  softened  patches  in  advanced 
stages  of  degeneration.  The  cerebral  arteries  contained  patches  of  a  yel- 
lowish or  atheromatous  nature.  The  spinal  cord  was  not  examined.  Both 
lungs  were  Ibund  to  be  tubercular,  and  in  the  middle  lobe  of  the  right  there 
was  a  large  cavity.  I  was  unable  to  find  any  tubercular  deposit  whatever 
in  the  brain  or  its  meninges.  The  left  frontal  convolutions  were  examined, 
but  no  disease  whatever  was  found. 

Hemingway  reports  the  following  interesting  case  of  left-sided  paralysis 
with  aphasia.1 

Jane  R.,  aged  30,  widow ;  occupation  seamstress ;  education  fair,  can 
read  and  write.  Entered  hospital  October  30,  1873.  Family  history 
good  ;  says  she  always  was  a  healthy  woman  tiH  present  illness.  Admits 
having  had  a  sore  on  genitals  five  years  ago.  Cicatrices  are  at  present 
visible  on  forehead,  which  are  probably  a  result  of  tubercular  syphilides; 
says  they  came  there  five  years  ago.  Her  left  eye  shows  the  result  of  an 
old  ophthalmia,  which,  it  was  supposed,  was  of  gonorrhceal  origin.  '  For 
two  years  past  has  had  slight  palpitations  on  exertion.  Always  used  her 
right  hand  in  her  occupation.  Four  months  ago,  one  night  when  she  was 
going  to  bed  she  became  suddenly  speechless ;  there  was  no  paralysis 
whatever.  Next  morning,  on  attempting  to  arise,  found  her  left  arm,  leg, 
and  side  of  face  paralyzed ;  also,  with  loss  of  sensation  in  those  parts. 
Loss  of  speech  was  complete ;  and  hearing,  which  before  this  was  excel- 
lent, was  now  lost  in  left  ear.  Her  tongue  was  only  affected  in  sensation ; 
she  was  not  able  to  appreciate  sweet  substances  placed  on  the  tongue ; 
sense  of  smell  also  lost.  About  one  month  after  this  attack,  i.  e.,  three 
months  ago,  improvement  began  in  speech,  face,  and  lower  extremity,  and 
has  continued  since  then.  Upper  extremity  began  to  improve  one  month 
ago.  Sphincters  have  not  been  affected.  Is  a  medium-sized  woman, 
pretty  well  nourished ;  mental  faculties  good,  with  exception  of  loss  of 
memory,  constituting  well-marked  amnesic  aphasia.  Is  unable  to  recol- 
lect many  words,  names  of  objects,  as  hat,  key,  handkerchief,  pencil,  etc. ; 
though  she  can  readily  repeat  them  on  being  told,  she  forgets  them  imme- 
diately afterwards.  Is  unable  to  read  continuously,  omitting  words,  and 
giving  up  from  inability  to  fix  attention.  On  attempting  to  write  the 
letters  of  the  alphabet,  the  result  was  A  B  C  D  S  G  H  I ;  but  when  the 
letters  were  separately  told  her,  she  wrote  them  down  easily.  Partial 
paralysis  remains  on  left  side  of  face  ;  cannot  close  eyelids  tightly.  Sen- 
sation is  lost  to  a  great  extent  in  left  side  of  face,  and  in  left  nostril.  Does 

1  Medical  Record,  March  4,  1876. 


172  DISEASES    OF   THE    CEREBRUM    AND    CEREBELLUM. 

not  wince  on  the  application  of  aqua  ammonia  to  left  nostril,  nor  when 
the  conjunctiva  or  same  side  is  touched  with  an  irritant.  Hearing  poor 
on  left  side.  Taste  is  impaired  anteriorly  and  posteriorly  on  left  side  of 
tongue. 

Dynamometer,      •!       *  ,'         '      I      outer  circle. 
(     right,  80,     ) 

^Esthesiometer  is  valueless,  on  account  of  loss  of  sensation  of  reaction 
to  pain.  Does  not  wince  on  pinching  arm,  but  does  on  palm  of  hand  and 
tips  of  fingers.  Perception  delayed;  takes  about  three  seconds.  Can 
raise  arm  to  level  of  shoulder,  a  little  stiffly.  Can  flex  and  extend  fore- 
arm and  fingers,  but  slowly.  Heart  sounds  normal.  Walks  without 
elasticity.  Sensation  in  leg  as  in  arm.  Reflex  action  lessened.  Electro- 
muscular  contractility  good. 

The  accumulation  of  reported  cases,  however,  in  which  the  lesion  was 
on  the  led  side,  leaves  no  doubt  in  regard  to  this  question.  Jackson 
and  Ramskill  report  40  cases  of  right  hemiplegia  with  aphasia,  and 
but  one  of  left  hemiplegia.  Ogle1  reports  25  cases  all  with  the  lesion  in 
the  left  hemisphere,  though  there  were  morbid  changes  in  some  of  these 
in  other  parts.  In  not  one  of  these  where  the  lesion  was  on  the  left  side 
was  there  undisturbed  speech.  Magnan1  reported  thirty-one  cases  of 
aphasia,  and  in  all  but  four  was  there  right-sided  hemiplegia.  Trousseau, 
in  18G8,  had  collected  all  the  cases  he  could  find,  the  number  being  over 

r  O 

one  hundred,  and  in  all  but  ten  there  was  right-sided  paralysis.  Seguin8 
has  collected  4(i  cases  from  the  records  of  the  New  York  Hospital,  and  in 
all  but  three  there  was  right  hemiplegia.  Hammond  has  collected  243 
cases  of  right  hemiplegia  with  aphasia,  and  but  17  of  left.  Thus  it  is 
settled,  I  thiuk,  that  the  left  side  of  the  brain  is  that  which  contains  the 
apeech  -centre. 

The  question  as  to  the  relative  frequency  of  right  and  left  hemiplcgiu 
naturally  arises,  and  from  the  inspect  ion  of  a  large  number  of  cases  it  will 
be  seen  that  there  is  a  very  slight  preponderance  of  the  former. 

Browne,4  from  Baillargor's  tables,  says  that  "  in  aphasia,  right  is  to  left 
hemiplegia  sus  l.>  is  to  1." 

By  the  following  table  it  will  be  seen  that  there  is  very  slight  prepon- 
derance of  right -sided  paralysis,  and  the  comparison  between  the  infre- 
quenc.y  of  aphasia  with  left  hemiplegia,  and  the  slight  difference  between 
the  relative  frequency  of  occurrence  of  both  forms,  is  inconsiderable. 

Casoe  of  hemiplegia.  K.  L. 

°i-rl«         •                   ....       75  43  S2 

Aiulrnl                         ....       136  73  63 

Baillarger HO  58  52 

821  174          147 


1  St.  Cieo.  Hosp.  Reports,  vol.  ii. 

*  Bull,  de  I'Acad&niede  Medecine. 

s  Quarterly  .Journal  of  Psychological  Medicine,  18G1,  xxx.  663. 

4  W.  Riding  Reports,  vol.  ii.  p.  284. 


APHASIA.  173 

As  to  the  exact  site,  Seguin  tabulates  545  cases,  in  all  of  which  but  31 
the  lesion  was  in  the  left  anterior  lobe.  Why  the  left  side  is  the  seat, 
especially  when  embolism  or  thrombosis  is  the  cause,  has  already  been 
explained  by  the  fact  that  the  left  middle  cerebral  artery  is  that  which 
is  in  the  most  direct  line  from  the  heart.  The  next  link  in  the  chain, 
which  is  the  question  of  valvular  disease,  and  its  connection  with  loss  of 
speech,  has  been  pointed  out  by  H.  Jackson,  who  has  found  that  valvular 
disease  was  nearly  always  associated  with  hemiplegia,  and  connected  with 
loss  of  speech.  He  has  seen  more  than  50  of  these  cases. 

In  my  own  experience,  and  my  records  show  8  cases  of  right  hemiple- 
gia with  aphasia  in  which  I  made  autopsies,  there  were  other  lesions, 
but  always  some  trouble  in  the  course  of  the  middle  cerebral  artery.  I 
therefore  agree  fully  with  the  majority  of  observers,  that  loss  of  speech 
depends,  except  in  rare  instances,  upon  lesions  in  the  left  hemisphere,  but 
that  it  may  also  follow  a  lesion  in  the  other  hemisphere.  Both  Brown- 
Sequard  and  Van  der  Kolk  have  advanced  theories— the  first,  that  articulate 
speech  is  a  reflex  process  ;  and  the  latter,  that  it  is  seated  in  the  olivary 
bodies.  This  last  view  was  held  by  Willis,  Solly,  and  others.  Laycock 
is  of  opinion  that  these  organs  are  "  subservient  to  the  emotions  through 
the  muscles  of  the  face  and  tongue  by  language,  and  emotional  cries  and 
sounds."  And  he  says  :  "  It  is  by  no  means  improbable,  however,  that 
the  emotional  movements  of  the  hands,  as  well  as  of  the  tongue  and  face, 
are  likewise  under  their  direction.  They  are,  therefore,  to  be  considered 
as  regulative  ganglia  to  the  motor  centres  of  the  facial,  hypoglossal,  and 
limb  nerves  in  the  medulla  oblongata  belonging  to  the  substrata  of  the 
sensory  tract." 

Dr.  Herbert  Major,1  in  a  very  complete  article  upon  the  microscopical 
anatomy  of  the  island  of  Reil,  sums  up  his  conclusions  as  follows  :— 

"  1.  The  cortical  layers  of  the  insula  agree  in  number,  order,  and  general 
arrangement  with  those  of  the  vertex,  but  the  cells  of  the  third  layer  are 
in  the  insula  generally  smaller  than  at  the  vertex.  The  vessels  and  neu- 
roglia  present  no  peculiarity. 

"  2.  The  various  gyri  forming  the  insula  present  a  similar  structure. 

"  3.  No  difference  of  structure  can  be  detected  in  the  right  as  compared 
with  the  left  insula. 

"  4.  The  method  of  union  of  the  white  matter  with  the  cortex  is  in  the 
insula  similar  to  that  observed  in  other  lobes." 

The  departure  from  the  healthy  state  is  seen  in  enlarged  vessels,  a 
shrunken  appearance  of  the  cells  of  the  first  layer  and  a  diminution  in  their 
number,  together  with  even  a  change  in  the  cell-contents,  the  nuclei  being 
broken  down  and  agglomerated  at  the  centre.  The  cells  of  the  second  and 
third  layers  have  lost  their  processes,  and  the  protoplasm  contains  granular 
debris,  while  the  other  cells  of  the  lowermost  layers  suffer  the  same  changes 
as  well  as  transposition. 

1  West  Riding  Reports,  vol.  vi.  1. 


174  DISEASES    OF   THE    CEREBRUM    AND    CEREBELLUM. 

Aphasia  may  be  dependent  upon  any  form  of  brain  disease  which  pro- 
duccs  disorganization  of,  or  pressure  upon,  the  third  frontal  convolution  or 
piirtn  immediately  adjacent.1  Among  the  common  diseases  which  lead  to 
the  structural  changes  are  central  hemorrhage,  thrombosis  or  embolism. 
tumor,  or  sclerosis,  as  well  as  certain  forms  of  meningitis.  Age  appears 
to  play  but  a  small  part  in  the  production  of  this  condition,  except  so  fat- 
as  it  influences  cerebral  hemorrhage,  embolism,  or  the  other  diseases  just 
mentioned. 

Very  few  examples  of  aphasia  in  very  young  persons  have  been  reported, 
for  vascular  neuroses  are  quite  unusual  among  children,  and  right  hemi- 
plegia,  with  a  lesion  in  this  particular  part  of  the  brain,  is  of  rare  occur- 
rence. A  case  was  reported  by  Eulenburg  which  was  quite  unique.*  The 
patient  was  eight  years  old ;  two  years  before  he  had  had  scarlet  fever, 
and  six  weeks  after  the  development  of  the  disease  there  were  convulsions 
and  coma,  followed  by  right  hemiplegia  with  aphasia.  The  paralysis 
almost  subsided  in  two  weeks.  He  speaks  but  two  words,  viz. :  "  Ach," 
which  he  always  uses  for  "  nein,"  and  "  Ja,"  with  which  he  answers 
all  other  questions.  The  fact  that  dropsy  and  albuminuria  had  existed 
induced  the  author  to  infer  the  presence  of  softening  of  the  central  organ 
of  speech.  That  disease  of  the  island  of  Reil  is  not  always  the  cause  of 
aphasia  is  proved,  1  think,  by  the  fact  that  aphasia  has  existed  with  dis- 
ease of  other  parts  of  the  brain  while  the  speech-centre  was  in  a  normal 
condition;  and  tumors  have  been  found  involving  the  corpora  striata,  and 
other  parts  of  the  motor  tract,  but  not  affecting  the  integrity  of  the  third 
frontal  convolution. 

Aphasia  of  a  temporary  character  may  depend  upon  functional  conditions, 
such  as  cerebral  congeal  ion,  indigestion,  or  as  the  result  of  fright  or  other 
emotional  forms  of  excitement,  or  may  be  connected  with  epilepsy  or  hys- 
teria, Kiseh*  re|Hirts  three  cases  of  transitory  aphasia  due  undoubtedly  to 
cerebral  congestion.  One  of  these  was  a  very  stout  woman  who,  having 
drank  a  very  large  quantity  of  carbonic  acid  water,  fell  to  the  floor  after 
being  dizzy,  but  did  not  lose  consciousness.  This  seizure  was  followed  by 
headache,  and  later  by  complete  aphasia.  She  subsequently  recovered. 
Two  rases  of  aphasia  of  a  similar  character  are  reported  by  Bcrger.  * 

Habershon*  presents  an  example  of  aphasia  which  was  caused  by  fright. 
A  much  more  rare  variety  of  the  disease  is  that  which  is  connected  with 


1  Among  fifteen  cases  reported  by  Sander*  there  were  two  in  which  the  origi- 
nal lesion  was  found  in  tin-  left  parietal  lobe,  iu  some  of  the  bundles  of  fibres 
radiating  from  the  corpus  striatuin. 

*  Hvrlin  Mcd.  Geselbchaft,  July,  18G9. 

3  Berliner  Klin.  NYochciischrift,  1869,433. 

4  \Yicn.  Mt-d.  \Y<>rli. ,  1HG9,  102. 

*  l.t null >u  Lancet.  1S70,  vol.  ii.  402. 


*  Archiv  fur  Psychiatric,  ii.  38. 


APHASIA.  175 

epilepsy.  Three  such  cases  were  published  by  Allbutt.1  One  of  these 
patients  fell,  striking  on  his  left  temple ;  some  time  afterwards  epilep- 
tiform  attacks  appeared  with  paralysis  of  the  right  arm  and  leg.  The 
second  case  was  that  of  a  woman  aged  fifty,  who  had  had  epileptic  con- 
vulsions of  a  bilateral  character  for  two  years.  After  the  attack  she 
was  somewhat  aphasic,  and  "had  a  mental  vision  of  the  words,"  but 
was  unable  to  speak  them.  This  condition  of  affairs  lasted  for  two 
hours.  The  third  patient  was  a  man,  thirty  years  of  age ;  there  was  no 
loss  of  consciousness,  but  attacks  of  hypergesthesia  in  the  right  arm  and 
hand,  followed  by  blindness,  lasted  for  twenty  minutes  or  longer,  and  was 
succeeded  by  speechlessness  lasting  two  hours. 

Diagnosis — In  making  the  distinction  between  aphasia  and  other 
difficulties  of  speech,  we  are  apt  to  be  misled  by  defects  in  articulation, 
dependent  upon  incoordination  or  paralysis  of  the  tongue,  or  by  certain 
mental  irregularities,  or  sometimes  by  congenital  mutism.2  We  are  to  bear 
in  mind  the  fact,  that  there  may  be  transitory  aphasia,  but  that  organic 
disease  of  the  speech-centre  is  generally  of  permanent  duration ;  and  that 
there  are  but  very  few  exceptions  to  this  rule.  The  speech  defects  which 
are  of  a  local  character  are  symptomatized  by  the  patient's  inability  to 

1  Med.  Times  and  Gazette,  1869,  vol.  i.  p.  491. 

2  Dr.  Browne,*  of  the  West  Riding  Asylum,  recently  examined  29  cases  of 
morbid  affections  of  language,  or  all  in  the  existing  population  of  the  Crichton 
Institution  at  Dumfries;   14  of  these  were  females,  and  15  males.     Of  these, 
which  he  arranged  in  three  classes,  he  found  among  the  women :    "  1 .  Intermittent 
mutism  5,  in  one  connected  with  the  catamenia.     2.  Constant  mutism,  7  :  of  these 
one  had  been  a  public  singer  ;   1  when  roused  could  with  difficulty  articulate, 
having  facial  paralysis;    1  could  not  walk  in  consequence  of  spinal  deformity; 
1   was  an  idiot  laboring  under   phthisis ;    1  uttered   cries  when  suffering  pain, 
o.    One  was  reduced  to  monosyllabic    utterances.      4.    One    manifested    inces- 
santly, day  and  night,  irresistible  loquacity. 

Among  the  males:  "Intermittent  mutism,  1.  2.  Constant  mutism,  5:  in  J 
the  mutism  is  of  twenty  years'  duration ;  in  1  it  is  accompanied  by  tremor  of  the 
limbs ;  in  a  third,  who  attempted  to  cut  his  throat,  there  is  unintelligible  mutter- 
ing in  soliloquy.  3.  One  was  reduced  to  monosyllabic  utterances.  4.  Two 
manifested  constant  loquacity  :  in  one,  an  idiot,  there  is  congenital  left  hemiplegia  ; 
in  the  other,  who  is  healthy,  the  loquacity  is  so  great  and  rapid  that  the  words 
run  into  each  other  so  that  he  seems  to  speak  in  long  sentences.  5.  Two  pre- 
sent symptoms  of  general  paralysis ;  the  articulation  is  indistinct  or  unintelligible, 
(i.  In  one  case  there  appeared  to  be  the  omission  of  the  first  syllable  of  every  word, 
followed  by  alternate  mutism  and  loquacity.  7.  In  one,  an  idiot,  language  is 
limited  to  a  few  words,  and  these  are  exclusively  oaths,  with  congenital  right 
hemiplegia,  and  club-foot.  8.  Two  idiots  emit  nothing  but  acute  inarticulate  cries  ; 
one  roars  like  a  wild  beast."  There  was  no  paralysis  in  these  cases  except  of 
the  face  in  two  general  paralytics,  and  of  the  lower  extremities  in  two  idiots,  the 
paralysis  in  these  latter  cases  being  congenital. 

*  Op.  fit.  p.  297. 


176  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

speak  at  all,  though  he  may  fully  convince  us  of  his  ability  to  form  words 
and  appreciate  their  meaning  ;  and,  moreover,  he  can  always,  should  there 
not  be  paralysis  of  the  hand  or  forearm,  write  any  word  that  he  may  wish 
to  speak.  This  is  not  the  case  in  aphasia.  In  lighter  forms  of  tongue 
paralysis  there  is  no  trouble  about  the  selection  of  words,  but  simply  a 
clumsiness  in  pronunciation,  and  in  many  of  these  forms  evidences  of 
local  muscular  weakness,  in  connection  with  the  speaking  apparatus, 
draw  attention  to  the  real  nature  of  the  trouble.  A  disease  presenting 
these  local  defects  is  a  so-called  glosso-pharyngeal  paralysis.  The  same 
condition  of  affairs  is  met  with  in  general  paralysis  of  the  insane,  but  with 
this,  as  well  as  other  troubles  of  the  same  kind,  there  are  various  other 
symptoms  which  accompany  the  speech  defect,  such  as  mental  impairment, 
with  peculiar  delusions  and  muscular  trembling.  Hysteria  sometimes  gives 
rise  to  a  very  curious  speech  derangement,  which,  in  its  strictest  sense,  can 
hardly  be  called  aphasia.  The  patient  occasionally  introduces  obscene 
and  profane  words  in  place  of  others  more  conventional.  A  form  of  speech 
trouble  described  by  Window1  and  Komberg*  is  expressed  by  mimicry  of 
individuals,  who  speak  to  the  patient  or  who  talk  within  earshot.  He 
closely  imitates  the  tones  of  their  voices  and  mannerisms,  and  repeats  the 
word.*  addressed  to  him,  besides  mimicking  their  gestures  and  attitudes. 
These  phenomena  are  occasionally  seen  among  the  insane.  Romberg  luis 
called  this  morbid  state  echo/alia.  I  have  at  present  a  case  under  obser- 
vation who  is  an  example  of  this  kind,  only  his  infirmity  does  not  exist  to 
so  marked  a  degree  as  in  the  cases  of  the  two  observers  above  mentioned. 
My  patient  is  an  idiot,  and  possesses  but  very  little  mental  power.  He 
can  point  to  his  mouth,  places  his  hand  upon  his  abdomen  when  hungry, 
and  can  call  attention  to  his  bodily  needs  by  equally  simple  gestures,  but 
beyond  this  he  is  more  an  automaton  than  a  living  being.  When  asked  a 
question,  for  instance,  "How  are  you?"  he  repeats  the  two  last  words, 
"Are  you?"  and  "Why  don't  you  answer?"  he  replies,  "Don't  you 
answer?"  He  invariably  repeats  the  last  two  or  three  words  of  any  ques- 
tion that  may  be  put  to  him,  so  that  his  answers  are  but  echoes  of  the 
questions. 

In  the  early  speech  disturbances  of  left  hemiplegia,  or  organic  diseases 
of  the  brain,  the  patient's  attempts  to  articulate  will  result  in  a  clumsy  and 
mispronounced  word  ;  while  in  aphasia  his  articulation,  be  it  ever  so  lim- 
ited, is  rarely  imperfect,  his  "  yes"  or  "  no"  being  fairly  pronounced,  or,  if 
he  has  improved  so  far  as  to  be  able  to  pronounce  but  a  part  of  a  word,  he 
will  do  this  distinctly,  while  jmrhaps  the  other  syllables  will  either  be  not 
pronounced  at  all,  or  in  such  a  way  as  to  be  utterly  unintelligible.  There 
are  generally  with  aphasia  great  impatience  and  embarrassment,  mimicry, 
and  gesticulation,  which  are  evidences  of  mortification  arising  from 
the  knowledge  of  his  failing,  and  his  gestures  take  the  place  of  words. 
In  agraphia  the  handwriting  or  results  of  attempts  at  writing  must  be 


1  Obscure  Diseases  of  the  Brain  and  Mind,  Am.  ed.,  p.  343. 

1  A  Manual  of  the  Nervous  Diseases  of  Man,  Syd.  Trans.,  vol.  ii.  p.  431. 


APHASIA.  177 

compared  with  specimens,  such  as  would  be  made  by  patients  who  are 
insane,  ataxic,  or  paralyzed,  and  it  is  necessary  for  us  to  carefully  note  the 
omission  of  words,  or  combination  of  syllables  which  bear  no  relation  to 
one  another,  as  well  as  the  character  of  the  patient's  composition.  If  he  be 
insane,  he  will  not  admit  any  absurdities  to  which  he  may  give  expres- 
sion, but  with  the  aphasic  the  case  is  different,  for  he  always  evinces 
his  chagrin  when  he  finds  that  he  has  written  the  wrong  word,  and 
endeavors  to  correct  his  mistakes.  There  are  cases  spoken  of  by  Bacon1 
and  others,  in  which  the  only  evidence  of  the  patient's  insanity  is  his 
writing,  but  even  here  the  defect  is  more  in  the  expression  of  a  disordered 
mental  state  than  in  an  impairment  of  the  communicating  faculty.  The 
handwriting  of  the  general  paralytic  sometimes  closely  resembles  that  of  the 
aphasic  patient,  but  in  the  first,  with  time  there  is  progressive  impair- 
ment, while  in  the  other,  if  anything,  there  is  improvement. 

The  medico-legal  questions  which  may  arise  in  regard  to  the  responsi- 
bility of  aphasia  are  worthy  of  consideration.  The  aphasic  of  course  may 
suffer  an  intellectual  impairment,  which  lasts  a  shorftime  after  the  attack. 
This  is  not  necessarily  accompanied  by  a  loss  of  judgment.  It  is  more  a 
condition  of  mental  sluggishness,  and  it  will  not  do  to  say  that  the  indi- 
vidual is  incompetent.  The  aphasic  makes  intelligent  efforts  to  communi- 
cate, even  though  he  may  not  be  able  to  do  so.  He  gesticulates,  and  tries 
to  explain  himself,  and  the  expression  even  of  his  eyes  tells  of  everything 
but  intellectual  unsoundness.  Additional  evidence  of  softening  in  dementia 
throws  an  entirely  different  light  upon  the  matter,  but  even  then  it  must 
be  remembered  that  aphasia  is  not  necessarily  associated  with  such  states. 

A  case  of  interest  is  reported  by  M.  Lucas  Championnieres  :2  "  The  ques- 
tion was  raised  in  this  particular  instance  a  propos  of  a  case  in  which  the 
patient,  in  spite  of  an  enfeebled  intelligence,  had  become  capable  of  writing 
with  the  other  hand.  He  could  not,  however,  write  if  left  to  himself,  and 
could  only  recopy  wrhat  was  written  and  set  before  him,  and  the  expert 
physicians  vainly  tried  to  make  him  recopy  a  power  of  attorney  or  a  will, 
while  he  willingly  wrote  any  ordinary  phrase  or  document  which  did  not 
bind  him  to  anything.  This  man,  then,  knew  perfectly  what  he  was 
doing,  and  the  Societe  de  Medecine  Legale  concluded  that  he  possessed 
still  thorough  intelligence  and  free  will  to  be  able  to  continue  to  enjoy  his 
civil  rights,  the  intellectual  debility  which  he  had  suffered  not  appearing 
to  be  sufficient  to  justify  what  the  French  laws  call  an  '  interdiction.'  ' 
The  society  recommended  that  he  should  be  taken  care  of  by  a  "  council," 
so  that  he  should  be  guaranteed  protection  against  danger  that  might  arise 
in  the  condition  of  his  affairs. 

We  must  bear  in  mind  the  existence  of  heart  trouble  should  it  exist,  or 
vegetations  and  other  indications  of  extraneous  disease  which  might  lead 
to  the  causation  of  thrombosis  or  embolism. 

1  On  the  Writing  of  the  Insane,  p.  12. 

2  Journal  de  Me>l.  et  de  Chir.  Prat.,  abst.  Br.  Med.  Journ.,  Sept.  15,  1877. 

12 


178  DISEASES   OF    THE   CEREBRUM    AND    CEREBELLUM. 

Prognosis The  view  we  are  to  take  of  our  patient's  condition  is  to 

b«  governed  entirely  by  the  question  whether  there  is  or  not  a  primary 
organic  disease,  its  imjKjrtance  and  the  character  of  the  aphasia.1  In  the 
light  forms,  such  as  result  from  fright  and  cerebral  congestion,  or  those 
connected  with  hysteria,  the  prognosis  is  exceedingly  good,  and  the  same 
is  the  case  when  it  is  the  result  of  protracted  fever.  Legroux  (op.  cit.  p. 
GO)  sj>eaks  of  an  aphasia  of  quite  temporary  duration,  which  is  occasionally 
of  gouty  origin,  or  connected  with  diabetes  or  albuminuria.  The  prognosis 
of  the  condition  itself  is  quite  good,  but  a  serious  indication  of  grave  cere- 
bral trouble.  Aphasia  with  paralysis  is  always  significant  of  deep  trouble. 
Such  an  aphasia,  when  it  occurs  with  hemiplegia,  may  persist  perhaps 
during  the  individual's  lifetime,  and  after  every  vestige  of  the  hemiplegia 
has  disappeared.  If  there  be  softening,  or  previous  acute  cerebral  dis- 
ease, or  if  there  IK?  evidence  of  arterial  degeneration,  or  valvular  deposits, 
the  ease  assumes  a  hopeless  aspect,  and  may  be  nearly  always  pronounced 
incurable.  Aphasia  as  the  result  of  traumatism  is  occasionally  relieved  by 
surgical  interference. ' 

Treatment — Our  first  indication  is  to  improve,  if  possible,  the  or- 
ganic dise;ise,  and  sometimes  we  are  able  to  better  the  patient's  condition 
to  a  great  degre e.  Should  there  be  hemiplegia,  contractures,  or  other  evi- 
dences suggestive  of  degeneration  of  the  cerebral  tissue,  we  will  find  our- 
selves jKiwerless  to  help  our  patient  materially.  It  is  only  when  aphasia 
exists  as  an  isolated  symptom  that  very  active  measures  are  followed  by 
some  show  of  success.  In  such  a  case  local  blood-letting,  purgation,  and 
the  use  of  ergot,  and  the  bromides,  may  completely  relieve  the  condition ; 
and  even  when  the  disease  is  established,  and  the  destruction  of  the  speech 
centre  has  been  limited,  there  is  a  possibility  of  improving  the  patient's 
partially  lost  faculty.  Systematic  education,  and  the  training  of  the  left 
hand,  and  the  development  of  the  right  side  of  the  brain,  may  result  in  an 
increase  in  the  patient's  facility  of  communicating.  In  rare  cases,  viz., 
those  of  traumatic  origin,  it  may  do  well  to  use  the  trephine.  Broca,  un- 
der the  heading,  "  La  Topographic  Cranio-C^rebrale,"*  described  experi- 
ments made  by  him  to  determine  the  relation  of  the  cranial  bones  with 
underlying  parts;  and  Turner8  has  made  additional  observations,  and 
given  rules  for  determining  this  relation.  Figure  20  is  taken  from  Tur- 
'ner's  article,  and  1  have  slightly  modified  it  so  that  the  point  where  the 
trephine  may  \w  used  is  indicated.  This  instrument  may  be  also  em- 
ployed in  aphasic  patients  at  parts  where  the  depressions  of  bone  have 
resulted  from  head  injury. 

Fig.  2O — "Diagram  showing  the  relations  of  the  convolutions  to  the 
skull.  K.  The  fissure  of  Rolando,  which  separates  the  frontal  from  the 

'  In  one  ease  report^  by  Bateman,  the  patient  recovered  almost  entirely,  and 
he  rould  pronounce  every  word  distinctly,  with  the  exception  of  those  containing 
the  IftU-r  P. 

1  Revue  d' Anthropologie,  tome  v.  No.  2,  1876. 

3  Journal  of  Anatomy  and  Physiology,  vola.  xii.,  xiv.,  1873,  1874. 


CEREBRAL    SCLEROSIS. 


179 


parietal  lobe.  PO.  The  parieto-occipital  fissure  between  the  parietal  and 
occipital  lobes.  S.  The  fissure  of  Sylvius,  which  separates  the  temporo- 
sphenoidal  from  the  frontal  and  parietal  lobes.  SF,  MF,  IF.  The 
supero-,  mid-,  and  infero-frontal  subdivisions  of  the  frontal  area  of  the  skull ; 


External  indication  of  Island  of  Reil.     (After  Turner.) 

the  letters  are  placed  on  the  superior  middle  and  inferior  frontal  convolu- 
tion. SAP.  The  supero-antero-parietal  area  of  the  skull.  IAP.  The 
infero-antero-parietal  area  of  the  skull.  IPP.  The  infero-postero-parietal 
area  of  the  skull ;  the  letters  are  placed  on  the  mid-temporo-sphenoidal 
convolution.  O.  The  occipital  area  of  the  skull ;  the  letter  is  placed  on 
the  mid-occipital  convolution.  Sq.  The  squamoso-temporal  region  of  the 
skull;  the  letters  are  placed  on  the  mid-temporo-sphenoidal  convolution. 
AS.  The  ali-sphenoid  region  of  the  skull;  the  letters  are  placed  on  the 
tip  of  the  supero-temporo-sphenoidal  convolution.''  The  circle  indicates 
the  point  at  which  the  trephine  is  to  be  applied. 


CEREBRAL  SCLEROSIS. 

Synonyms — Sclerencephalia  ;  atrophia  cerebri.  Tabes  cerebri.  Atro- 
phy of  the  brain. 

Definition — An  induration  of  the  nervous  substance  consisting  in 
increase  of  connective  tissue,  and  atrophy  and  destruction  of  the  nervous 


180  DISEASES   OF    THE    CEREKRUM    AND    CEREBELLUM. 

elements,  constitutes  the  condition  known  generally  as  sclerosis.  The 
French  writers  have  applied  the  terms  "  Sclerose  en  plaques  dissemine'e," 
"rubane*","  "  jie'riphe'riques,"  and  "  diffus"  to  the  disease;  adopting  iln->c 
names  in  regard  to  the  character,  site,  and  form  of  the  lesion.  Such  ex- 
pressions, while  making  the  nomenclature  more  exact,  imply  delicate  dis- 
tinctions which  are  not  always  to  be  made,  and  do  very  well  only  when 
applied  to  appearances  witnessed  .after  death,  but  are  not  so  valuable 
when  making  a  diagnosis  before  death.  I  prefer  to  use  the  terms  "  dif- 
fused sclerosis"  of  the  brain,  "  cerebro-spinal  sclerosis,"  and  "  spinal 
sclerosis."  Even  this  nomenclature  is  open  to  objection,  for  it  is  very  rare 
for  sclerosis  of  any  kind  to  be  confined  to  either  the  brain  or  cord,  though 
such  involvement  of  the  organ  not  originally  affected  may  be  of  late  <!:itr. 
To  confirm  this  statement  I  may  allude  to  the  ocular  symptoms  wliicli 
characterize  the  early  manifestations  of  posterior  spinal  sclerosis,  or  the  loco- 
motory  defects  that  are  to  be  seen  in  some  sclerosed  conditions  supposed  to 
\tc  peculiarly  cerebral.  I  may  furthermore  add  that  in  all  forms  of  sclero- 
sis there  are  generally  points  of  induration  found  after  death  in  both  brain 
and  cord.  Nevertheless,  it  is  important  for  us  to  make  distinctions  in  the 
manner  and  origin,  course  and  termination  of  the  various  forms  of  the  dis- 
ease, and  we  must  therefore  be  contented  with  an  anatomical  division. 


DIFFUSED  CEREBRAL  SCLEROSIS. 

The  older  writers  were  in  the  habit  of  giving  the  title  "  atrophy  of  the 
brain"  to  a  condition  of  that  organ  which  was  undoubtedly  that  which  we 
are  now  discussing.  It  is  probably  one  of  the  most  imperfectly  understood 
nervous  diseases,  and  in  many  instances  the  diagnosis  cannot  be  made 
during  life. 

Symptoms — The  cerebral  condition,  which  is  tardy  induration  of  an 
unlimited  region,  and  does  not  consist  in  scattered  deposits,  is  a  slowly 
develojH-d  morbid  state,  and  is  expressed  by  a  train  of  rather  obscure 
symptoms,  the  most  striking  of  which  are  contractions  and  epileptiform 
convulsions,  impairment  of  mental  power,  and  various  affections  of  speech. 
In  some  cases  the  conditions  date  from  infancy,  and  the  characteristic  fea- 
ture is  want  of  development  of  the  extremities.  In  others,  a  condition  of 
imbecility  exists,  in  which  the  patient  leads  almost  a  vegetative  life.  One 
case  (No.  II.),  which  I  shall  relate,  was  of  this  kind.  Her  last  years  of 
life  were  spent  in  bed,  and  for  a  long  time  there  were  dementia  and  uncon- 
scious discharges  from  the  bladder  and  Ixnvels.  Some  of  these  cases  begin 
later  in  life,  and  the  first  indications  may  be  either  tremor  or  an  epilepti- 
form convulsion,  and  subsequently  various  disturbances  of  motility,  such, 
for  instance,  as  spastic  contraction  of  the  muscles  of  the  arm  and  leg. 
The  fingers  become  twisted,  deformed,  and  distorted  so  as  to  be  useless. 
Tremor  is  not  rare,  and  as  the  disease  advances  there  may  be  various 
other  symptoms,  such  as  paralysis  and  muscular  atrophy,  as  well  as  glosso- 
labial  paralysis.  Psychical  disturbances  are  early  symptoms,  and  a  species 
of  dementia  is  rapidly  produced. 


CEREBRAL    SCLEROSIS.  181 

CASE  I — Mary  J.,  the  patient,  a  girl  14  years  old,  was  brought  to  me 
during  the  month  of  September,  1871.  She  had  been  very  ill  some  six 
years  before,  and  from  what  I  learned  from  the  mother,  the  attack  of 
illness  must  have  been  scarlatina,  or  some  other  eruptive  fever.  Her  con- 
valescence was  slow,  and  attended  by  convulsions  of  an  epileptoid  charac- 
ter. She  slept  much  of  the  time,  and  seemed  dull  and  stupid.  Her 
memory  became  impaired,  so  that  her  mother  was  obliged  to  take  her  from 
school,  and  when  allowed  to  play  she  quarrelled  with  the  children  in  the 
neighborhood,  and  became  so  warlike  that  it  was  found  necessary  to  keep 
her  at  home.  When  she  had  suffered  for  over  a  year  in  this  way,  she 
began  to  lose  her  power  of  speech,  and  when  she  attempted  to  converse 
with  those  who  spoke  to  her  she  talked  in  an  unintelligible  manner ;  the 
tongue  "seemed  to  be  paralyzed."  In  1868  her  arms  became  very  weak, 
and  trembling  grew  violent  when  she  made  any  manual  effort.  This  loss 
of  power,  which  was  observed  more  in  the  right  arm,  became  so  great  that 
she  was  unable  to  use  it  in  any  way  whatever.  After  a  year  or  so  the 
arm  became  rigid  and  atrophic,  and  within  twelve  months  the  other  arm 
followed.  She  is  now  in  a  condition  of  imbecility.  She  holds  her  head 
very  far  forward  when  she  walks,  her  chin  being  raised.  The  right  pupil 
is  slightly  larger  than  the  left.  There  is  ataxic  loss  of  speech,  the  tongue 
being  entirely  out  of  control,  but  nevertheless  she  incessantly  tries  to 
talk.  Her  senses  are  but  slightly  impaired,  and  it  may  be  said  she  hears 
well,  if  we  can  place  any  reliance  upon  the  rough  tests  I  made,  such  as 
speaking  to  her  behind  her  back.  Her  sensibility  to  pain  is  not  appa- 
rently lost,  for  she  gives  expression  to  signs  of  suffering  when  she  is  pinched, 
but  she  complains  of  dysnesthesia. 

Her  right  arm,  forearm,  and  hand  are  semiflexed  and  rigid,  and  the 
atrophy  of  the  palmar  muscles  suggests  the  "  main  en  griffe."  Her  nails 
are  long  and  thick,  and  the  skin  not  only  of  this  hand,  but  that  covering 
the  hand  and  arm  of  the  other  side,  is  blue  and  cold.  The  flexors  carpi 
radialis,  palmaris  longus,  pronator  radii  teres,  and  other  muscles  upon  the 
anterior  aspect  of  the  forearm  were  atrophied  and  contracted,  as  well  as 
the  extensors  communis  and  minimi  digiti.  This  appearance  was  found 
on  both  sides,  but  more  so  on  the  right.  When  she  makes  any  voluntary 
movement,  the  tremor  occurs,  and  it  is  like  that  which  marks  other  forms  of 
this  disease ;  that  is  to  say,  it  is  increased  by  persistence  in  the  attempt. 
The  arms  are  the  only  parts  affected  by  the  tremor.  Her  convulsions 
occur  about  twice  a  week. 

CASE  II — M.  S.,  aged  18  years,  admitted  to  hospital  June  21,  1873. 
When  patient  was  fifteen  months  of  age  she  had  her  first  epileptic  con- 
vulsions. These,  according  to  her  stepmother,  have  gradually  increased  in 
number.  At  ten  years  of  age  she  became  paralyzed.  The  paralysis  affected 
her  right  side,  and  came  on  gradually,  without  loss  of  consciousness  ;  and 
it  has  increased  so  that  at  present  all  the  muscles  of  the  extremities,  and 
some  of  those  of  the  face,  are  paralyzed.  Sensibility  is  not  affected.  She 
has  imperfect  control  of  the  voluntary  muscles,  and  does  not  use  them 
readily  ;  and  when  spoken  to  does  not  appear  to  appreciate  what  is  desired 
immediately. 

Dynamometer:  left  side  15,  right  side  19. 

The  sesthesiometer  was  not  used,  as  the  patient  was  too  much  demented 
to  appreciate  what  was  wanted. 

Her  head  is  very  large,  the  patient  being  of  ordinary  stature.  The 
saliva  flows  continually  from  the  corner  of  her  mouth,  and  her  complexion 


'82  DISEASES    OF    THE    CEREBRUM    AND   CEREBELLUM. 

is  dusky  and  bad.      The  muscles  are  all  more  or  less  atrophied.      Heart 
and  lungs  are  normal ;  no  murmurs  other  than  the  venous  hum  of  anaemia. 

The  patient  came  under  my  care  in  June,  187G.  She  was  then  in  a 
condition  of  profound  dementia.  She  had  been  in  bed  for  some  months, 
and  when  I  examined  her  I  found  her  condition  to  be  the  following : — 

There  were  no  constant  ocular  defects,  no  ocular  paralysis,  and  the 
pupils  responded  well ;  but  there  had  been  occasional  attacks  of  unconscious- 
ness, attended  by  nystagmus,  when  her  eyeballs  would  move  from  left  to 
right.  There  was  slight  paralysis  of  the  buccal  muscles,  and  the  mouth 
was  almost  constantly  open  ;  while  a  profuse  secretion  of  saliva  drooled 
from  the  angle  of  the  mouth  and  over  her  undergarments  and  bed-clothes. 
Her  mouth  contained  partially  masticated  food,  of  which  there  was  an 
accumulation  between  her  teeth  and  cheeks  on  either  side.  Her  teeth 
were  very  filthy,  and  the  gums  tender  and  bleeding.  No  appreciative 
facial  paralysis  was  detected.  When  spoken  to  she  smiled  in  an  inane 
manner,  but  did  not  attempt  to  speak.  She  was  occasionally  very  apt  to 
cry  for  several  hours  at  a  time,  and  seemingly  without  cause.  Her  posi- 
tion in  bed  was  an  exceedingly  uncomfortable  one ;  she  usually  reclined 
ii|K>n  her  left  side,  the  head  drawn  down  to  the  same  side ;  and  it  was 
agitated  by  coarse  tremors,  which  ceased  when  she  slept.  Her  right  arm 
and  forearm  were  drawn  to  her  chest,  and  likewise  agitated  by  almost 
constant  tremors.  Her  left  arm  was  also  adducted,  and  the  forearm  semi- 
flexed  ;  while  the  fingers  were  extended.  Tremors  of  the  same  character 
agitated  this  member.  The  thighs  and  legs  were  drawn  up,  but  did  not 
seem  to  be  quite  so  rigid  as  the  arms,  and  there  was  great  atrophy  of  all 
four  extremities.  She  passed  her  excreta  unconsciously,  and  a  bedsore 
had  formed  upon  the  left  buttock.  Voluntary  power  was  absent  almost 
entirely,  and  I  do  not  remember  having  seen  her  change  her  position  in 
bed  from  the  time  I  first  saw  her  until  her  death.  Sensibility  to  pain  was 
very  much  lost,  and  reflex  excitability  was  nil.  Perhaps  some  of  this 
want  of  sensibility  was  due  to  the  horny  condition  of  the  plantar  skin. 
She  had  a  great  many  general  convulsions,  attended  by  turgescence  of  the 
mirface  vessels,  and  nystagmus.  She  continued  in  this  condition  during 
the  year,  improving  slightly  during  this  time  in  regard  to  the  number  and 
violence  of  convulsions,  but  gradually  growing  weaker. 

Dec.  26,  1876,  1.30  P.  M.  Being  fed  with  stewed  meat  she  had 
three  convulsions  in  rapid  succession,  while  her  mouth  was  filled  with  food. 
Attendant  states  that  she  first  became  cyanotic,  but  her  teeth  were  so 
clenched  that  the  nurse  was  unable  to  extract  the  food.  As  soon  as  the 
*|»asins  relaxed,  she  thrust  her  fingers  in  the  mouth  of  the  patient,  and  re- 
moved a  piece  of  meat,  but  the  patient  was  dead. 

Autopsy  IK  hours  after  death — No  food  found  in  larynx  or  fauces. 
Membrane  of  brain  congested  and  thickened  ;  the  gray  matter  of  all  the 
convolutions  was  of  the  consistency  of  the  white  of  a  hard-boiled  egg. 

I  afterwards  can-fully  examined  the  brain,  and  found  patches  of  advanced 

Bcleroeed  tissue  over  the  cortex,  and  throughout  the  gray  and  white  matter 

of  other  parts  of  the  hemispheres.     The  induration  was  so  general  that 

the  brain  seemed,  as  u  whole,  quite  hard  and  tough.      The  arteries  were 

throughout,  and  the  calibre  of  the  vessels  was  quite  reduced. 

—This  patient  presents  evidences  of  cerebral  sclerosis,  which 
were  evidently  of  very  early  origin.  The  patient  is  at  present  in  the  Epi- 
leptic and  Paralytic  Hospital.  Her  early  history  is  somewhat  meagre. 
She  gives  a  history  of  epilepsy,  and  has  attacks  several  times  a  week.  Her 


CEREBRAL    SCLEROSIS.  188 

mind  is  very  feeble,  and  she  has  attempted  suicide  several  times.  The 
atrophy  is  one-sided,  and  there  is  probably  atrophy  of  the  left  side  of  the 
brain.  The  following  history  and  table  of  measurements  were  furnished 
by  my  predecessor,  Dr.  Janeway  : — 

E.  B.,  aged  19  years  ;  state,  single.    Admitted  to  hospital  May  1,  1868. 

Examination — Head  :  no  facial  paralysis  or  deviation  of  tongue  ;  no 
atrophy  of  tongue  ;  pupils  normal,  no  strabismus  ;  hearing  good,  as  is  also 
common  sensibility.  Right  upper  extremity :  shoulder-joint  is  freely 
movable ;  elbow  cannot  be  fully  extended  ;  hand  flexed  and  extremely 
pronated  ;  muscles  of  hand  to  a  certain  degree  rigid  ;  fingers  flexed,  thumb 
not  rigid  ;  marked  atrophy  of  entire  arm  ;  skin  of  fingers  soft  and  sodden, 
but  no  other  changes  of  nutrition. 

Measurements — Middle  sternal  notch  to  coracoid  process  :  right  side, 
4|-  inches  ;  left  side,  4|  inches.  Edge  of  acromion  to  external  condyle  : 
right  side,  10£  inches  ;  left  side,  10^  inches.  External  condyle  to  styloid 
process  of  ulna :  right  side,  7^  inches  ;  left  side,  8^  inches.  Apex  of 
acromion  to  styloid  process  :  right  side,  1\  inches  ;  left  side,  8  inches. 

1st  metacarpal  bone  (index  finger)  :  right  side,  50  mm. ;  left  side,  55 
mm.  Metacarpal  bone  (little  finger)  :  right  side,  47  mm. ;  left  side,  50 
mm.  Metacarpal  (thumb)  :  right  side,  40  mm. ;  left  side,  43  mm. ;  right 
index,  65  mm. ;  left  index,  70  mm.  Little  finger  :  right  side,  53  mm. ; 
left  side,  60  mm. 

Thenar  eminence,  thickness  of:  right,  31  mm.;  left,  35mm.  Hypo- 
thenar  eminence,  thickness  of:  right,  20  mm.;  left,  24  mm. 

Vertebral  prominence  to  edge  of  acromion  :  right  side,  6^  inches ;  left 
side,  7|-  inches.  Inner  edge  scapula  to  supra-spinal  notch,  to  deltoid : 
right  side,  12f  inches;  left  side,  14f  inches.  Length  inner  border  sca- 
pula :  right,  5^  inches ;  left,  Q\  inches. 

Semi-circumference  thorax  (4th  rib):  right,  13^  inches;  left,  14^ 
inches. 

Sensibility  of  right  hand  normal  in  every  respect.  Dynamometer :  first 
trial  in  left  hand,  18  ;  second  trial,  10.  Hardly  any  power  of  right  hand, 
but  reflex  movements  are  readily  excited  in  it.  Circumference :  right 
arm,  8-|  inches  ;  right  forearm,  8^  inches  ;  left  arm,  9^  inches  ;  left  fore- 
arm, 9f  inches. 

Lower  extremities  :  left,  length  of  fibula,  1 3£  inches  ;  right,  length  of 
fibula,  13^  inches;  right  calf,  ll£  inches;  left  calf,  12f  inches.  Lower 
edge  patella  to  lower  edge  external  malleolus  :  right,  13£  inches  ;  left,  13| 
inches.  Anterior  edge  inner  malleolus  to  end  of  great  metatarsal :  right, 
4^  inches  ;  left,  4^  inches.  Circumference  over  heads  of  metatarsal  bones  : 
on  right  side,  1\  inches  ;  on  left  side,  1\  inches.  Anterior  sup.  spinous 
process  to  lower  malleolus  :  right,  28£  inches  ;  left,  28|  inches.  Supra- 
sternal  notch  to  lower  edge  of  external  malleolus  :  right,  45j  inches  ;  left, 
48|  inches. 

Sensibility  of  legs  good  in  all  respects.  Difference  of  malleoli  as  she 
lies  in  bed,  ^  inch. 

Causes So  little  is  known  in  regard  to  the  circumstances  favoring 

the  development  of  this  disease,  that  beyond  the  mention  of  certain  facts 
of  age  and  sex  nothing  more  can  be  said  in  connection  with  etiology. 
Women  seem  to  be  more  affected  than  males,  and  we  may  consider  that  it 
is  usually  a  condition  that  begins  in  infancy  and  progresses  slowly,  or  is 
arrested ;  or,  on  the  other  hand,  it  may  begin  in  advanced  life,  and  pro- 


184  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

gress  moro  rapidly.  In  one  case  which  I  have  seen,  syphilis  had 
probably  something  to  do  with  its  development. 

Morbid  Anatomy. — Those  authors  who  have  made  autopsies  have 
found  a  condition  of  density  of  the  white  matter,  the  same  being  shrunken 
and  more  firm  at  the  centre  of  the  hemisphere  than  at  the  periphery. 
When  a  microscopical  examination  is  made,  the  brain-tissues  are  found  to 
show  ap|>earances  which  are  highly  characteristic.  The  connective  tissue 
will  be  found  to  be  proliferated,  and  to  present  a  fibrillated  appearance. 
Corpora  amylacea  are  often  present,  and  we  usually  find  granular  deposits 
in  the  blastema.  The  new  tubes  are  quite  changed  in  character,  and  are 
.shrunken  and  attenuated.  The  axis  cylinder  may  have  disappeared,  and 
its  place  may  be  filled  by  a  granular  substance.  The  nerve-cells  are  greatly 
altered,  their  prolongations  being  torn  off,  and  their  contents  granular. 
Oil-globules  are  often  found  scattered  over  the  field,  and  sometimes  col- 
lected about  the  bloodvessels.  These  vessels  are  generally  much  increased 
in  size,  and  their  walls  are  thickened,  and  covered  by  a  granular  deposit. 
If  the  gray  matter  be  the  part  affected,  we  shall  find  an  unusual  develop- 
ment in  the  bloodvessels. 

I  have  s|K)ken  of  the  involvement  of  the  cranial  nerves.  It  is  not  un- 
eoinmon  to  find  at  the  roots  of  this  nerve  a  sclerosed  point  which  has 
involved  the  nuclei. 

Diagnosis — Diffused  sclerosis,  in  its  incipiency,  maybe  mistaken  for 
cerebral  softening,  but  though  the  two  diseases  seem  very  much  alike,  the 
absence  of  severe  pain,  and  variations  of  temperature  in  the  latter,  as  well 
as  subsequent  progress  of  the  disease,  will  enable  us  to  decide;  it  must  be 
borne  in  mind,  however,  that  in  the  great  number  of  cases  diffused  sclerosis 
begins  in  very  early  life.  The  congenital  non-development  which  we 
sometimes  see  will  be  recognized  by  the  absence  of  tremors. 

Prognosis  and  Treatment — The  former  is  excessively  bad,  and 
even  temporary  relief,  I  think,  is  out  of  the  question  in  the  great  majority 
of  cases.  I  have  never  seen  a  case  cured  ;  and  if  there  is  any  disease  of 
the  nervous  system  that  is  utterly  beyond  the  reach  of  drugs,  I  am  con- 
vinced that  it  is  this.  The  actual  cautery  has  been  used,  but,  as  far  as  I 
can  learn,  without  benefit.  Hammond  recommends  chloride  of  barium, 
and  claims  to  have  improved  the  condition  of  the  patient. 


BRAIN    TUMORS.  ]  85 


CHAPTER    VI. 

DISEASES  OF  THE  CEREBRUM  AND  CEREBELLUM 
(CONTINUED). 

BRAIN  TUMORS. 

WHEN  the  brain  chances  to  be  the  .seat  of  a  morbid  growth,  whether 
vascular,  parasitic,  homologous,  or  heterologous,  we  may  be  apprised  of 
the  existence  of  such  a  new  formation  by  a  train  of  symptoms  which  have 
no  very  constant  character;  or  the  tumor  may  involve  a  large  part  of  the 
brain  without  giving  rise  to  any  indications  of  its  presence  during  the  life 
of  the  patient.  There  is  no  regularity  as  to  the  grouping  or  appearance 
of  symptoms,  although  the  very  valuable  researches  of  Hughlings  Jackson 
have  enabled  us  to  define  the  position  of  the  morbid  intracranial  growths 
with  much  greater  certainty  than  heretofore. 

Symptoms — We  may  group  the  prominent  symptoms  under  the 
following  heads: — 

1.  Convulsions. 

2.  Vomiting  and  vertigo. 

3.  Headache  and  cutaneous  hypenesthesia  or  anaesthesia. 

4.  Hemiplegia. 

5.  Paralysis  of  cranial  nerves. 

6.  Ocular  symptoms. 

7.  Psychical  disturbances. 

Convulsions — The  appearance  of  convulsions  as  the  only  indication  of 
brain  tumors  has  frequently  led  the  observer  to  make  a  diagnosis  of  epi- 
lepsy. However,  when  it  is  taken  into  account  that  there  is,  at  the  most, 
but  transitory  loss  of  consciousness — and  even  this  is  very  rare — during 
the  epileptiform  attack,  such  a  mistake  is  hardly  possible.  The  convul- 
sions may  be  general  or  local,  and  in  this  place  it  is  proper  to  refer 
to  the  connection  between  certain  cortical  lesions  produced  by  brain  tu- 
mors, and  consequent  convulsions  beginning  in  members  which  are  sup- 
posed to  have  motor  centres.  Among  sixteen  cases  collected  by  Hughlings 
Jackson  there  were  several  in  which  the  convulsive  seizure  began  in  the 
thumb  of  one  hand,  and  finally  became  general.  Cortical  lesions  were 
found  in  the  third  frontal  convolution.  In  another  the  epileptiform 
seizure  began  in  the  right  cheek,  and  still  another  is  reported  where  the 
right  arm  was  the  point  of  seizure,  with  subsequent  paralysis ;  and  after 
death  a  tumor  was  found  in  the  uppermost  frontal  convolution  on  the  op- 
posite side.  Upon  the  authority  of  Bastian1  and  Reynolds,  "  it  may  be 

1   Op.  cit.,  p.  493. 


186  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

.-t:it'-'l  that  convulsions  are  most  common  when  the  disease  is  situated  in 
the  interior  lobes  of  the  brain  or  in  the  cerebellum,  and  least  frequently 
when  the  anterior  lobes  are  affected." 

Ilughlings  Jackson  considers  that  psychical  disturbances  are  likewise 
connected  with  destruction  or  injury  of  the  posterior  lobes.  When  the 
growth  is  syphilitic,  the  presence  of  much  headache  before  the  convulsion 
is  the  rule.  Convulsions  may  be  the  first  symptoms  of  tumor,  and  when 
they  occur  in  advanced  life  there  is  always  occasion  for  suspicion.  Several 
writers  have  agreed  that  convulsions  and  other  symptoms  are  the  result  of 
irritation  of  parts  adjacent  to  the  tumor,  and  that  they  may  vary  in  ap- 
|M'aranee  and  severity  in  proj>ortion  to  the  local  disturbance  created  by 
the  growth  ;  for  this  reason  convulsions  may  appear  in  the  most  irregu- 
lar manner.  Pain  is  one  of  the  earliest  and  most  persistent  symptoms. 
It  is  nearly  always  localized,  and  is  very  intense,  especially  if  the  me- 
ningcs  be  affected  in  any  way,  when  it  may  be  combined  with  muscular 
twitehings.  It  is  rare  for  it  to  subside  for  an  extended  period,  and  then 
reappear;  and  in  such  cases  it  is  highly  probable  that  the  growth  has 
either  expanded  in  some  other  direction,  or  that  the  tissues  have  become 
accustomed  to  its  presence  in  the  manner  suggested  by  Niemeyer.  Pain 
aggravated  at  night  is  highly  suggestive  of  a  syphilitic  tumor. 

Photophobia  is  sometimes  a  symptom,  and  intolerance  of  noise  is  a  de- 
cided feature,  while  vertigo  is  produced  by  very  slight  irritation,  and  it  has 
In-en  found  in  tumors  which  injure  the  corpora  quadrigemina  that  this 
occurs  when  the  patient  closes  his  eyes.  Such  was  noticed  to  be  the  case 
in  an  example  reported  by  Dr.  Duffin.  This  patient,  a  man  aged  twenty- 
five,  presented  the  following  symptoms :  A  dragging  of  the  muscles  at  tin- 
back  of  the  neck,  so  that  the  head  was  pulled  downwards  and  backwards, 
unsteady  walk,  vertigo  when  eyes  were  closed,  vomiting,  frequently  slow 
and  irregular  circulation,  obscured  intelligence,  double  optic  neuritis,  de- 
fective sight,  and  finally  coma.  A  gliomatous  tumor  was  found  which  had 
destroyed  the  pineal  gland,  and  extended  into  the  optic  thalamus.  Reel- 
ing is  commonly  associated  with  vertigo,  and  is  generally  symptomatic, 
of  a  growth  in  the  substance  of  the  cerebellum.  Symptoms  of  minor 
importance  are  cutaneous  aiwsthesia  or  hypertesthesia,  with  tingling  or 
formication  of  the  hands  or  feet.  Such  anaesthesia  may  affect  the  tract 
supplied  by  the  fifth  nerve,  while  deep  cerebral  pain  may  coexist.  This 
combination  is  almost  pathognomonic,  and  should  be  looked  upon  with 
suspicion. 

Hemiplegia  is  not  an  uncommon  symptom,  and  may  be  sudden  when 
produced  by  the  rupture  of  a  vessel;  or  of  gradual  origin,  as  the  result  of 
pressure  made  upon  important  parts  of  the  motor  tract  by  a  tumor  of  slow 
growth.  It  is  generally  a  late  symptom,  and  may  begin  by  paralysis  of  one 
member,  and  afterwards  of  the  other  of  the  same  side.  By  far  the  most 
interesting  paralyses  are  those  of  the  cranial  nerves,  because  of  their  value 
as  diagnostic  signs ;  and  not  only  may  the  optic  nerve  be  affected,  but  the 
auditory  motor  oculi,  and  even  the  fifth,  may  suffer  an  alteration  of  func- 
tion. 


BRAIN    TUMORS.  187 

Jackson  and  others  are  of  the  opinion  that  those  muscles  concerned 
more  in  the  execution  of  direct  voluntary  movements  are  often  affected 
in  a  greater  degree  than  those  which  perform  automatic  movements  almost 
exclusively. 

Paralysis  of  both  external  recti  muscles  occurred  in  one  of  Jackson's 
cases,  and  is,  perhaps,  one  of  the  most  significant  indications  of  the  pre- 
sence of  a  gummata.  Lateral  deviation  of  the  eyes  from  the  side  of  the 
lesion  is  also  a  form  of  cranial  nerve  paralysis  which  is  by  no  means  a 
rare  symptom.  In  a  case  reported  by  AfanaschifF,1  where  a  tumor  was 
found  in  the  right  crus,  there  was  dilatation  of  the  pupil  and  ptosis.  Par- 
tial paralysis  of  the  face,  showing  involvement  of  the  seventh,  and  actual 
deafness,  are  not  rare  consequences  of  injury  sustained  by  the  seventh 
nerve.2  When  the  fifth  nerve  is  affected,  as  in  one  of  Broadbent's  cases, 
there  is  generally  marked  anaesthesia  of  the  region  supplied  by  this  nerve, 
with  difficult  mastication,  deglutition,  and  articulation.  The  most  im- 
portant changes,  however,  are  seen  at  the  fundus  oculi,  and  by  some  optic 
neuritis  is  considered  to  be  a  positive  sign  of  brain  tumor.  Russel,3  in 
the  description  of  a  very  instructive  example,  details  an  examination  of 
the  fundus.  This  may  be  considered  a  typical  case,  although  the  retinal 
appearances  were  in  an  advanced  stage.  He  found  "  loss  of  vision  com- 
plete, neuro-retinitis  of  both  eyes.  Right  disk  comparatively  invisible, 
even  its  position  not  clearly  distinguishable.  Position  of  left  disk  indi- 
cated by  short  portion  of  retinal  vessels,  which  were  visible  near  their 
point  of  convergence.  Region  around  the  disk  in  each  eye  occupied  by 
large  irregular  patches  of  hemorrhage,  some  recent,  others  undergoing 
absorption.  Only  very  small  portions  of  retinal  vessels  are  here  and  there 
A'isible." 

Complete  atrophy  of  the  optic  disk  is  generally  to  be  observed  in  cases 
where  the  retinitis  has  existed  for  some  time. 

Htighlings  Jackson  calls  especial  attention  to  the  fact  that  loss  of  vision 
is  not  inseparable  from  optic  neuritis,  though  complete  blindness  often 
does  occur.  He  has  seen  cases  in  which  there  was  double  optic  neuritis, 
though  the  patients  were  able  to  read  the  smallest  type.* 

A  very  important  appearance  observed  at  the  fundus,  and  known  as 
"  choked  disk"  or  "  congestion  papilla,"  is  often  produced  by  brain  tumors. 
In  fact,  when  not  a  peripheral  condition,  it  is  almost  always,  according  to 
Swanzy,5  connected  with  intracranial  tumors,  hydrocephalus,  or  menin- 
gitis ;  but  when  it  is  produced  by  these  morbid  conditions  it  is  usually 
binocular.  "  Choked  disk"  may  be  caused  by  a  tumor  in  any  part  of  the 
brain,  whether  it  be  in  the  cerebellum  or  cerebrum,  and  it  is  not  necessary 

1  Wien.  Med.  Woch.,  1870,  No.  9. 

2  H.  Jackson  does  not  believe  that  tumors  of  the  cerebrum  or  cerebellum  pro- 
duce deafness,  unless  the  auditory  nerves  be  pressed  upon. 

3  Med.  Times  and  Gazette,  July  26,  1873. 

4  Royal  London  Ophthalmic  Hospital  Reports,  vol.  iv.,  1865. 

6  Signs  of  Congestive  Papilla  or  Clicked  Disk  in  Intracranial  Disease.  H.  R . 
Swanzy,  M.B.,  F.R.C.S.,  Dublin  Journ.  of  Med.  Science,  June,  1874. 


188  DI8EA8E8    OF    THE    CEREBRUM    AND    CEREBELLUM. 

that  the  optic  nerve  shall  be  implicated  either  at  its  origin  or  in  its  course. 
Another  fact  is  of  im|x>rtance,  viz.,  that  the  size  of  the  tumor  has  nothing 
to  do  with  the  production  of  the  condition,  and  a  small  tumor  may  pro- 
duce choked  disk  as  well  as  a  large  one.  The  appearance  of  choked  disk 
ig,  in  substance,  the  following.  The  disk  may  be  seen  to  be  prominent, 

Fig.  21. 


Choked  Diik.     (After  Leibrcich.) 

the  fibres  are  swollen,  and  the  papillary  region  is  sometimes  of  a  dark  red- 
dish-gray, much  change  of  color  being  due  to  passive  effusion  and  old 
hemorrhage.  The  disk  may,  in  other  cases,  be  of  a  bright  color.  There 
may  be  some  evidences  of  retinal  extravasation,  which  are  not  found  at 
any  great  distance  from  the  edge  of  the  disk,  and  Albutt1  says  not  more 
thai,  a  distance  of  the  radius  from  the  edge.  The  margin  of  the  disk  is 
concealed  by  infiltration  and  by  vascularity.  which  give  it  a  "mossy" 
ap|M*arance.  The  central  radiating  appearance  resembles  very  much  a 
scintillating  body,  while  the  retinal  veins  are  distended  and  tortuous,  are 
<|iiite  serpentine  in  their  course,  and  they  may  even  be  varicose. 

I  cannot  agree  with  Albutt.  who  considers  the  recognition  of  any  prom- 
inence of  the  disk  a  ditKcult  matter,  and  I  think  that  this  is  the  opinion 
of  the  majority  of  ophthalmologists. 

Sjieech  is  generally  involved  at  some  time  or  other,  and  psychical  trou- 
bles of  all  kinds,  but  more  frequently  the  asthenic  forms,  make  their 
appearance.  There  is  often  a  condition  of  hebetude  and  stupidity  which 
is  supposed  to  symptomati/c  a  tumor  in  the  posterior  lobes,  or  there  may 
be  mental  decay  06  a  most  grave  character.  Delusions,  loss  of  memory, 
change  of  temper,  suicidal  tendencies,  and  various  perversions  of  intelli- 
gence may  occur  in  any  case. 


1  The  Ophthalmoscope,  etc.,  1871,  p.  55. 


BRAIN    TUMORS.  189 

A  feature  of  cerebellar  tumor,  which  I  find  was  also  observed  by  Caton, 
was  the  assumption  by  the  patient  of  the  erect  position  as  a  means  of  relief 
from  the  nausea  and  desire  to  vomit.  This  author,1  in  reporting  a  case  of 
cerebellar  tumor,  alludes  to  the  inability  of  his  patient  to  regulate  his 
visual  coordination  ;  and  this  seems  perfectly  reasonable  when  we  consider 
the  paralysis  of  the  muscles  of  the  eyeball,  and  the  diplopia,  amblyopia, 
and  other  disturbances  of  visual  regulation. 

The  case  of  Miss  F.  is  in  some  ways  instructive,  although  it  lacks 
completeness,  as  it  does  not  contain  the  report  of  an  autopsy,  the  patient 
being  still  alive  (Oct.  16,  1877)  :— 

Miss  F.,  aged  37,  U.  S.,  school  teacher;  was  sent  to  me  by  Dr. 
Richard  F.  Derby,  in  July,  1876.  Seven  months  ago  her  present  trouble 
began  with  weakness  of  vision,  for  which  she  consulted  Dr.  Derby,  of 
Boston,  who  adopted  Dyerization  as  a  means  of  treatment.  In  Novem- 
ber, 1876,  she  began  to  complain  of  severe  localized  headache  on  the  left 
side  of  the  head.  This  symptom  was  constant  for  three  months,  and  to- 
wards the  end  of  this  period  a  gradual  hyperaesthesia  of  the  entire  left  side 
developed  itself,  which  is  now  present.  It  is  more  decided  for  three  or 
four  days  at  a  time,  when  there  is  a  lull.  There  is  also  strabismus,  which 
attends  the  paroxysms  of  acute  head  pain,  which  once  in  a  while  recur. 
In  December,  1876,  there  was  some  vomiting,  which  did  not  have  any 
connection  with  the  fulness  or  emptiness  of  the  stomach.  There  is  no  loss 
of  motor  power  in  the  upper  extremity  of  either  side,  but  the  left  leg  and 
foot  are  rather  weak,  and  there  is  some  awkwardness  in  progression,  the 
toe  dragging  slightly.  Slight  impairment  of  electro-muscular  contractility 
of  muscles  of  leg  and  thigh.  Dynamometer  on  left  side,  9  ;  on  right,  12, 
Slight  ptosis  of  left  eye,  occasional  diplopia, 

Dr.  Derby's  record  of  the  examination  of  her  eyes :  "  Neuro-retinitis 
o.  u.,  with  great  reduction  of  vision  o.  s.  ;  moderate  reduction  o.  d."  The 
patient  hears  subjective  rushing  sounds  on  left  side.  Is  slightly  hysteri- 
cal, and  suffers  from  menstrual  irregularities.  She  gives  no  history  of  any 
traumatism,  no  blow  or  fall,  nor  previous  illness.  Her  mother  and  father 
are  living,  but  of  decided  nervous  temperament ;  paternal  aunt  and  some 
of  mother's  connections  are  insane.  Maternal  grandmother  and  her 
brother  died  of  phthisis.  The  patient  has  had  night-sweats,  and  some 
pulmonary  symptoms.  There  is  no  specific  history. 

Upon  a  previous  visit  she  stated  that  there  was  great  formication  in  the 
sole  of  the  right  foot.  She  afterwards  went  to  her  home  in  Vermont,  when 
I  lost  sight  of  her,  but  have  subsequently  heard  of  the  advance  of  her 
symptoms. 

Morbid  Anatomy — Without  attempting  any  classification,  I  will 
briefly  allude  to  those  forms  of  intra-cranial  growth  most  often  met 
with.  Probably  that  which  is  most  common  is  Tubercle,  Among  young 
children  tubercle  is  found  sometimes  in  masses  of  considerable  size;  and, 
according  to  Wilks,  the  cerebellum  is  its  most  familiar  seat.  It  is  found 
as  a  cheesy  accumulation  of  dirty  green  color,  and  very  rarely  has  the  gray- 
ish appearance  of  the  deposit  been  found  in  other  parts  of  the  body.  These 

1  London  Lancet,  Oct.  31,  1875. 


190  DISEASES    OF    THE     CEREBRUM    AND    CEREBELLUM. 

musses  are  rather  dry,  and  decidedly  non-vascular,  and  if  a  collection  has 
been  arrested  in  its  growth  will  be  found  to  be  encysted,  and  may  be 
readily  removed.  If  of  progressive  growth,  the  limits  of  the  deposit  are 
blended  with  the  surrounding  brain-substance,  and  of  a  consistency  like 
cold,  white  glue.  Tuberculous  masses  are  rarely  single,  but  generally 
invade  several  regions  in  the  same  brain,  so  that  it  is  impossible  to  give 
any  very  satisfactory  table  which  will  throw  light  upon  the  question  of 
distribution.1 

Fox,  in  speaking  of  Jaccoud's  observation,  says  :  "  I  much  prefer  Jac- 
coud's  account  of  these  tubercles.  They  occupy  the  white  and  the  gray 
substance  equally,  and  present  themselves  under  the  form  of  small  isolated 
circumscribed  masses,  varying  in  number  from  one  to  twenty,  and  seldom 
exceeding  the  latter.  Their  volume  is  in  inverse  ratio  to  their  number. 
Pretty  often  they  are  the  size  of  a  cherry,  at  other  times  they  scarcely 
exceed  the  size  of  a  grain  of  wheat.  As  to  the  colossal  masses  which 
attain  to  the  magnitude  of  a  hen's  egg,  they  result  from  the  confluence  and 
fusion  of  several  spots  originally  distinct."1 

They  are  sometimes  separated  from  the  nervous  substance  by  a  sheath 
of  connective  tissue  and  bloodvessels.  In  this  connective  tissue,  which 
is  well  filled  with  vessels,  according  to  Virchow,3  the  new  granules  are 
formed,  and  are  impacted  with  the  central  mass,  and  become  cheesy. 
When  the  process  stops,  the  growth  is  found  to  be  surrounded  by  a  tough 
fibrous  coat,  which  is  sometimes  very  hard,  and  even  calcified  in  old  cases. 

Ogle4  has  re|K>rted  a  case  where  the  tuberculous  mass  had  broken  down, 
so  that  it  was  soft  and  pultaceous.  In  the  younger  subjects  tubercle  is 
generally  found  in  other  parts  of  the  body. 

Cancerous  growths  in  the  brain,  which  seem  to  affect  those  of  ad- 
vanced age,  take  much  the  same  form  that  they  do  in  other  parts  of  the 
lK)dy.  Encephaloid  and  scirrhus  are  the  commoner  forms,  though  melano- 
mutn  are  occasionally  found. 

The  investing  membranes  may  all  be  the  seat  of  cancer,  but  notably 
the  pia  mater  and  the  bony  walls  of  the  cranium  are  its  starting-points. 

'  (Jrasset*  has  clarified  bruin  tumor*:  1.  Those  of  the  embryonic  tissue  (tissu 
embryonnairc).  These  arc  the  Sarcomata — a.  Soft  sarcoma  ;  b.  Sarcoma  nevro- 
i/lii/ne  (^lionia)  :  r.  Sarcoma  rt'i//i'>/jVAj'/ue  (or  psammoma).  He  considers  that 
tlic  terms  glioma  and  psammoma  an-,  improperly  used ;  that  the  first  term  sugjjfsts 
more  tlu>  consistence  rather  than  the  character  of  the  tumor.  2.  Those  of  the 
connectirt  tissue,  which  are — a.  Myxoma  ;  b.  Fibroma;  c.  Lipoma ;  d.  Carci- 
noma; f.  Melanoma.  3.  Those  of  the  cartilaginous  tissue,  Chondroma.  4. 
Those  of  the  osseous  tissue,  Osteoma.  5.  Tho.su  of  the  epithelial  tissue,  Papil- 
loiiui.  6.  Those  of  the  nervous  tissue.  Neuroma.  7.  Tubercle.  8.  Syphilitic 
Tumors.  0.  Parasitic  tumors  (Hydatids),  Aneurism.  10.  Abscesses. 

*  Fox,  op.  rit.,  p.  l.r)l. 

s  Cellular  Pathology,  p.  523. 

4  Articles  in  Br.  and  For.  Mcd.-Chir.  Review,  1864  and  1865. 


*  Maladies  du  Systeme  Nerveux,  Paris  and  Montpellier,  1878,  p.  302. 


BRAIN    TUMORS. 


191 


In  this  case  the  cancerous  mass  grows  inwards,  where  it  meets  less 
resistance,  while  cancer  of  the  brain  itself  grows  outwards.  Cancerous 
masses  are  occasionally  very  large,  and  in  one  of  Russel's  cases  (to  which 
allusion  has  already  been  made)  the  cancerous  mass,  which  occupied  the 
right  parietal  region,  weighed  six  ounces  and  a  half.  These  tumors  pre- 
sent the  same  characteristics  which  they  possess  in  other  regions.  The 
encephaloid  variety  is  very  vascular ;  the  scirrhus  not  so  much  so,  and  is 
quite  hard.  The  carcinomatous  growth  presents  the  usual  appearance  of 


Fie.  22. 


Fig.  23. 


Tubercular  Deposit  about  Vessel. 


Sarcoma. 


cells  contained  in  the  alveoli  of  a  fibrous  network  or  stroma.     It  may  ex- 
ist alone  as  an  intracranial  growth,  or  coexist  with  cancer  of  other  organs. 

Fi<r.  25. 


G  uinnia. 


Psammoma 


The  cancerous  growth   invades  the  cerebral  substance,  though  generally 
the  dura  mater  and  the  other  meninges  may  be  the  parts  at  first  affected. 


192 


DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 


Syphilis  very  often  produces  changes  in  the  contents  of  the  cranium 
which  aire  quite  formidable.  Of  diffused  infiltration  I  will  not  speak,  but  of 
those  growths  known  as  gummata,  or  "  gummy  tumors."  The  meninges 
and  cortex  cerebri  are  commonly  the  parts  which  favor  the  syphilitic 


Fig.  26. 


Fig.  27. 


Eueephaloid. 


Glioma. 


deposit,*,  though  deeper  regions  may  very  often  be  invaded  by  the  trans- 
lucent reddish-gray  tumors  of  specific  origin.  The  interior  is  sometimes 
jelly-like  and  soft,  and  contains  minute  red  points,  while  the  periphery 
is  hard  and  fibrous.  The  tumor  proper  appears  to  be  separated  from  the 
surrounding  brain  substance  by  this  fibrous  covering,  though  there  is 
always  infiltration  into  the  parts  adjacent.  Syphilitic  growths  are  rarely 
single,  and  I  have  seen  a  number  of  them  in  the  same  brain.  Beneath 
the  microscope  the  tumor  seems  composed  of  round  cells  about  the  size 
of  white  corpuscles,  containing  a  single  nucleus.  These  round  cells 
occupy  the  centre  of  the  mass,  while  the  outer  portion  is  composed  of  a 
network  of  connective  tissue  containing  irregular  cells.1  The  dura  mater 
is  very  commonly  the  point  of  origin.  This  case,  for  the  history  of  which 
I  am  indebted  to  Dr.  Ryan,  was  diagnosed  by  him  during  life.  The 
l«itient  was  in  the  service  of  Dr.  Mason. 

William  llrowning,  net.  32,  native  of  the  United  States,  boatman  by 
occupation,  married,  was  admitted  to  the  Paralytic  and  Epileptic  Hospital 
of  Illack well's  Island,  on  March  13,  1877. 

The  patient  says  he  has  always  been  a  bard  drinker.  Had  been  a  very 
healthy  man  up  to  seven  years  ago,  when  he  contracted  syphilis,  and  has 
since  that  period  been  subject,  from  time  to  time,  to  outbreaks  of  the  dis- 


1  Tin-  syphilitic*  growth  may  sometimes  be  mistaken  for  that  of  a  tuberculous 
nature.  Niemever  has  reminded  us,  however,  "  that  in  syphiloma  the  passage 
from  the  cheesy  centre  to  the  broad,  grayish-white  peripheral  /one  is  very  gradual, 
while  in  infiltrated  growing  tuberculi  these  zones  follow  each  other  more  closely, 
and  in  tubemdes  that  can  be  turned  out  they  do  not  exist." 


BRAIN    TUMORS.  193 

ease  in  its  tertiary  form.  Two  years  ago  he  had  a  convulsive  attack, 
which  occurred  at  night ;  after  which  he  was  out  of  his  mind  tor  three 
weeks.  Since  that  time  he  has  been  subject  to  one  or  two  attacks  occur- 
ring every  month.  Since  admission,  the  patient  had  four  epileptiform  fits, 
characterized  by  clonic  spasms,  a  confused  and  perturbed  condition  of  the 
mental  faculties,  but  no  distinct  loss  of  consciousness.  A  premonitory 
feeling  of  great  terror  was  always  experienced  about  ten  or  fifteen  minutes 
prior  to  the  convulsion,  and  this  sense  of  dread  remained  for  some  time 
after  each  fit ;  these  seizures  being  always  followed  by  intense  headache 
and  debility,  which  generally  lasted  for  several  days.  The  patient's  sight 
had  failed  greatly  for  the  last  year ;  unfortunately  no  ophthalmoscopic 
examination  was  made.  His  memory,  he  said,  was  getting  very  much 
impaired,  and  any  mental  occupation  caused  violent  headache. 

April  28,  the  date  of  his  last  attack,  he  had  been  in  bed,  complaining 
of  severe  pains  in  the  head,  referred  chiefly  to  the  frontal  region  of  the 
right  side.  This  pain  was  always  greater  at  night ;  the  patient  complained 
of  no  other  trouble,  with  the  exception  of  great  weakness  and  anorexia, 
until  about  May  5,  when  slight  paralysis  of  the  muscles  on  the  right  side 
of  the  face  was  noticed,  especially  of  the  orbicularis  palpebrarum.  There 
was  also  a  distinct  loss  of  muscular  power  in  the  left  upper  extremity, 
which  was  colder  to  the  touch  than  the  right,  and  the  pulse  of  the  affected 
limb  was  feeble  and  compressible.  On  May  14  the  patient  became  some- 
what delirious,  and  remained  so  till  the  time  of  his  death.  On  the  17th  he 
began  to  cough,  and  expectorated  a  great  quantity  of  sero-mucous  fluid. 
Mucous  and  subcrepitant  rales  were  heard  over  all  the  anterior  surface  of 
both  lungs ;  a  change  in  the  pulse  and  temperature,  which  had  previously 
remained  normal,  was  now  noticed;  the  former  being  130,  and  the  tem- 
perature 103°.  Herpes  appeared  on  the  forehead  and  lips.  On  the 
morning  of  the  18th,  patient  was  in  a  semi-comatose  condition.  Pulse 
160,  temperature  104°.  He  died  at  2  o'clock  P.  M.  of  same  day. 

Autopsy  twenty -four  hours  after  death.  Rigor  mortis  passing  off;  body 
somewhat  emaciated ;  suggillation  of  posterior  portion  of  body.  Old 
cicatrices  (large)  over  left  tibia,  also  several  smaller  ones  scattered  over 
exterior  and  upper  portions  of  body. 

Head  :  The  dura  mater  is  markedly  thickened  over  portion  of  the  parie 
tal  bone  of  right  side  adjacent  to  temporal  bone,  and  is  also  adherent  to 
a  tumor  beneath  in  the  brain-substance.  On  three  points  on  inner  sur- 
face of  parietal  bone  (right)  are  spots  of  necrosis,  the  size  of  a  dime, 
which  involve  the  inner  table.  The  dura  can  easily  be  separated  from 
the  bone,  but  not  from  the  surface  of  the  tumor.  This  tumor  is  three 
inches  from  above  downwards,  and  two  and  one-half  inches  from  before 
backwards.  It  is  firm,  and  of  a  yellowish  color.  The  brain-substance 
directly  beneath  it  is  the  seat  of  softening  (inflam.),  while  beyond  this 
point,  and  extending  in  a  direct  line  to  optic  thalamus  of  right  side,  the 
brain-substance  is  softened  and  diffused.  The  outer  border  of  posterior 
portion  of  optic  thalamus  is  in  the  same  condition,  while  the  meninges  and 
vessels  are  normal. 

Thorax :  Lungs.  Bands  of  adhesion  on  right  side,  and  a  few  at  apex  of 
left.  In  the  lower  lobe  of  right  are  numerous  spots  of  lobular  pneumonia  in 
gray  stage.  On  anterior  margin  of  right  lung  some  emphysema,  and  also 
at  apex  of  left  lung.  Otherwise  both  lungs  show  marked  hypostatic  con- 
gestion and  oedema. 

Heart  soft  and  flabby.     Seat  of  post-mortem  decomposition. 
13 


194  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

Abdomen:  Liver  increased  in  length;  evidences  of  peri-hepatitis.  On 
surface  of  liver  are  seen  several  old  cicatrices,  which  dip  down  into  liver 
substance.  The  parenchyma  in  patches  is  softened  and  fatty  (syphilitic 
liver  ?). 

Spleen  increased  in  size.  Capsules  thickened  in  patches  ;  parenchyma 
diffluent. 

Kidneys  about  normal  size.  On  stripping  capsule  it  brings  away  por- 
tion of  kidney  tissue.  Surface  appears  granular,  and  in  some  points  shows 
lobulation.  iSection  shows  tubules  swollen,  and  of  yellowish  color.  There 
appear  to  be  about  normal  relations  between  cortical  and  pyramidal  por- 
tions. Pelvis  and  ureters  normal. 

Bladder,  stomach,  and  intestines  normal. 

Parasitic  Growths  (Hydatids  and  Cysticerci) — Hydatids  are  always 
contained  in  a  delicate  cyst  (except  when  they  occupy  the  lateral  ven- 
tricles), and  there  may  be  several  in  the  same  capsule.  The  cysts  are  of 
variable  size,  and  sometimes  attain  the  magnitude  of  a  fair-sized  orange 
(Reynolds).  They  are  occasionally  very  large,  and  the  centre  of  either 
hemisphere  seems  to  be  their  common  site.  Cysticerci,  which  are  very 
small,  and  are  sometimes  contained  in  cysts,  rarely  exceed  the  size  of  a 
large  marble,  but  are,  however,  more  often  found  uninvested,  and  they 
may  be  from  one  to  several  hundred  in  number.  They  prefer  the  cor- 
tex, and  are  often  found  beneath  the  pia  mater.  It  seems  to  me  that 
these  would  be  among  the  most  interesting  cases  for  the  observation  of 
irritation  of  the  motor  centres;  usually,  however,  there  are  very  slight  in- 
dications of  their  presence. 

Komberg,  while  making  some  experiments,  found  that  the  existence  of 
Cysticerci  in  the  cerebelli  of  several  sheep  accounted  for  the  peculiar  roll- 
ing convulsions  that  he  had  observed. 

Cysts,  which  are  not  the  secondary  result  of  softening  or  hemorrhagic 
disease,  are  very  rare,  and  are  not  usually  larger  than  pin-heads. 

Gliomata,  which  are  directly  formed  from  the  connective  tissue,  are 
more  common  in  the  posterior  lobes  and  in  the  cerebellum  than  in  any 
other  locality.  The  soft  and/rm  are  the  two  varieties. 

G.  L.  C.,  let.  2G,   of   nervous   temperament ;    general    health    good ; 
parents  both  ulive  ;  no  nervous  tendency  ;  never  had  syphilis.    Four  years 
ago  the  patient  became  irritable  and  morose,  and  continued  so  till  January, 
IHTtt.     He  then  devoted  himself  to  hard  study,  and  rarely  took  exercise 
or  amusement.     Two  months  afterwards  he  became  debilitated,  and  had 
attacks  of  vomiting,  which  occurred  in  the  morning,  and  were  relieved 
somewhat  by  the  upright  j>osition.     In  the  following  April  a  loss  of  steadi- 
ness of  the  lower  limbs  was  noticed.     He  reeled,  and  a  sudden  fright  would 
cause  him  to  full.     He  no  longer  went  alone  on  the  street ;  when  he  did 
so,  he  reeled,  staggered,  and  felt  conscious  that  he  was  the  object  of 
His  face  became  congested,  and  his  nose  very  red,  although 
i  habits  were  very  good.     lie  went  to  the  seashore,  but  nevertheless 
rew  worse,  and  derived  no  benefit  from  the  change.     About  this  time 
•lopia  troubled  him,  and  he  tried  various  devices  to  correct  this  visionary 
ifficulty,  such  as  shutting  one  eye  and  looking  across  his  nose  with  the 
er,  but  without  relief.     In  August,  violent  headache  developed  itself, 
and  vomiting  was  frequent.     He  could  not  look  up  or  throw  his  head  back 


BRAIN    TUMORS.  195 

without  dizziness  and  pain.  Cathartics  and  local  blisters  did  no  permanent 
good,  nor  did  the  bromides. 

May,  1875.  The  patient  presents  the  same  symptoms.  He  is  very 
much  troubled  by  headache,  which  is  paroxysmal.  He  staggers  wildly, 
and  his  vision  is  not  improved.  On  the  day  before  his  death  he  went  to 
see  some  friends,  and  on  his  return  complained  of  a  terebrating  pain  in  the 
back  of  his  head.  He  went  to  bed,  and  slept,  under  the  influence  of 
chloral  hydrate.  When  his  wife  awoke  in  the  morning,  she  found  him 
dead.  He  had  evidently  died  without  any  convulsions,  or  she  would  have 
been  aroused.  The  night  before  his  death  there  was  some  mania,  and  he 
shouted  words  of  the  different  languages  he  spoke — German,  French, 
Italian — in  a  confusing  jargon. 

At  no  time  was  there  impairment  of  speech  or  deglutition  ;  there  were 
never  ptosis,  deafness,  loss  of  smell  or  taste.  Paralysis  was  never  observed, 
nor  were  there  convulsions  of  any  kind. 

Autopsy  eight  (?)  hours  after  death.  The  scalp  was  cut  through,  and 
the  exposed  surfaces  were  almost  black  with  blood.  On  removing  the 
bone  the  meninges  were  found  hyperaemic  to  a  marked  degree,  the  spaces 
were  engorged  beneath  the  arachnoid,  and  in  the  ventricles  was  a  large 
amount  of  yellowish  fluid,  the  former  being  puffed  out  by  the  serum 
under  the  surface  Nothing  unusual  was  noticed  in  the  hemispheres 
beyond  the  hyperasmia  before  alluded  to,  and  careful  slicing  of  the  basal 
ganglia  revealed  nothing  of  importance.  The  texture  of  the  nervous  sub- 
stance was  normal.  At  the  base  of  the  brain  a  very  different  state  of 
affairs  was  found  to  exist.  From  before  backwards  there  were  evidences 
of  acute  inflammatory  action,  the  left  side  more  particularly  being  the  seat 
of  softening.  The  right  crus  of  the  optic  commissure  was  very  much  dis- 
organized. There  was  a  well-organized  membrane,  very  pink  and  net-like, 
which  extended  over  the  inferior  surface,  one  band  binding  down  the  left 
root  of  the  optic  commissure. 

Beneath  the  lining  membrane  of  the  fourth  ventricle,  at  a  point  beneath 
the  lower  and  anterior  part  of  the  cerebellum,  was  an  effusion,  with  soft- 
ening of  this  organ.  This  membrane  was  bellied  out,  and  had  evidently 
produced  death  by  direct  pressure  upon  the  calamus  scriptorius. 

At  a  point  corresponding  to  the  middle  of  the  lower  vermiform  process 
of  the  cerebellum  was  a  small  hard  tumor,  about  two  centimetres  in  length, 
one  and  a  half  in  breadth,  and  the  same  in  thickness,  which,  when  cut, 
disclosed  a  red  jelly-like  centre,  and  a  hard  fibrous  exterior,  resembling, 
somewhat,  a  syphilitic  growth.  The  line  of  demarcation  between  the 
healthy  tissue  and  the  circumference  of  the  tumor  was  very  well  marked. 
Beneath  the  microscope  Dr.  E.  G.  Janeway  and  I  found  it  to  be  a  glioma 
of  the  firmer  kind,  there  being  a  fibrous  structure  containing  the  charac- 
teristic cells. 

After  hardening  pieces  of  the  cerebellum  and  the  medulla  oblongata,  I 
examined  them  microscopically.  The  evidences  of  disorganization  of  the 
nervous  elements  at  the  nuclei  of  the  vagus  were  apparent.  The  nerve- 
cells  were  deprived  of  their  processes,  and  the  nerve-tubes  were  broken. 
The  sections  of  the  cerebellum  were  made  contiguous  to  the  tumor,  and 
here  I  found  considerable  thickening  of  the  neuroglia  and  disappearance 
of  nerve-tissue,  while  the  vessels  were  very  much  increased  in  size. 

Amyloid  bodies,  connective  tissue  cells  and  vessels  are  found  to  compose 
these  tumors,  which  may  sometimes  attain  a  diameter  of  several  inches. 
The  peri-vascular  spaces  are  filled  with  adventitious  matter,  and  the  calibre 


196  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

of  the  vessels  is  very  much  reduced.  These  growths  may  undergo  fatty 
degeneration  or  absorption.  The  hard  varieties,  I  think,  predominate, 
ami  they  are  very  easy  to  recognize. 

Papillomata,  both  of  the  vessel  and  meninges,  are  not  uncommon. 

Alyjromata,  which  Jaccoud  describes  as  having  their  source  of  origin 
from  the  spheno-occipital  suture,  are  quite  rare,  as  are  Lipomata.  The 
former  are  usually  of  large  size,  have  a  gelatinous  appearance,  and  at 
times  are  cloudy.  The  latter  consist  of  large  cells  filled  with  fat,  and  are 
transparent  and  shining. 

Sarcomata  may  be  met  with  as  soft  masses,  which  contain  "  fusiform 
bodies,  nuclei,  and  vessels,"  or  else  round  cells  closely  packed.  They  are 
lobulated,  and,  when  cut,  present  a  pinkish-gra^y  and  softened  surface,  and 
sometimes  contain  central  fluid.  The  soft  sarcoma,  according  to  Grasset, 
is  found  among  young  children  in  the  deeper  parts  of  the  brain,  and  remains 
dormant  for  some  time,  not  giving  rise  to  any  symptoms,  the  cells  being 
usually  round  ("  globo-cellulaire").  With  fatty  degeneration  the  tumor 
may  undergo  a  change,  so  that  it  resembles  the  yellow  plates  in  cerebral 
softening.  It  usually  has  a  surrounding  vascular  network,  and  is  easily 
separated  from  the  brain-substance. 

Fibrous  tumors  are  quite  rare,  but  are  sometimes  met  with.  Lebert  has 
seen,  in  one  case,  seventeen  small  fibrous  tumors  upon  the  ependyma  of 
the  lateral  ventricle,  varying  from  the  size  of  a  pea  to  that  of  a  small 
cherry-stone.  These  tumors  are  of  a  white  color  and  globular  shape,  and 
they  are  separated  from  the  healthy  brain-tissue  by  a  space  in  which  the 
vessels  are  enlarged.  They  are  easily  enucleated,  and  quite  hard  and 
dense.1 

Aneurisms. — One  of  the  most  interesting  and  important  forms  of  intra- 
cranial  growths  are  those  of  a  vascular  character.  I  have  taken  occasion  to 
refer  to  the  smaller  aneurisms  described  by  Bouchard  and  Charcot,  the  so- 
called  miliary  aneurisms,  which  are  of  minute  size ;  but  large  aneurisms, 
arising  from  such  arteries  as  the  middle,  anterior  and  posterior  cerebral, 
bosilar,  and  communicating  arteries,  may  be  even  an  inch  in  diameter. 
These,  with  miliary  aneurisms  of  small  size,  are  generally  found  to  coexist 
in  the  brain.  Gougenheim1  has  found  that  aneurism  of  the  basilar  artery 
was  much  more  common  than  any  other  form,  and  that  of  sixty-eight  cases 
seventeen  were  of  this  artery.  It  is  rare,  however,  that  the  disease  can  be 
diagnosed  during  life,  and  but  two  or  three  cases  have  been  reported  where 
their  presence  was  recognized  by  symptoms,  and  afterwards  verified  by  an 
autopsy.  One  of  these  cases  was  reported  by  Coe,s  another  by  Holmes,* 
and  a  third  by  Humble.' 

An  interesting  case  of  cerebellar  aneurism  is  reported  by  Bristowe  : — 

J.  B.,  a  lighterman,  let.  5G,  was  admitted  on  the  2Gth  of  October,  1858, 


1  Annt.  Path.,  vol.  ii.  p.  71. 

2  Gougenhcim,  Dub.  Journ.  of  Med.  Sci.,  Nov.  1870. 

1  Association  Med.  Journal,  Nov.  1855.  4  System  of  Surgery. 

4  Lancet,  Oct.  2,  1875. 


BRAIN    TUMORS. 


197 


for  an  attack  of  acute  rheumatism  (gout  ?).  No  distinct  account  of  the 
previous  duration  of  his  illness  was  obtained.  Five  days  after  admission 
he  complained  of  severe  epigastric  pain,  and  had  some  vomiting.  Shortly 
afterwards  he  became  comatose,  and  continued  so  until  his  death,  which 
took  place  on  the  2d  of  November. 

Post-mortem  Examination. — There  was  a  considerable  amount  of  serum 
both  on  the  surface  and  in  the  ventricles  of  the  brain  ;  and  much  athero- 
matous  and  earthy  deposit  in  the  arteries  at  the  base,  and  their  branches. 
In  the  right  corpus  striatum  was  a  small  apoplectic  cyst,  but  in  other 
respects  the  brain-substance  appeared  healthy.  In  the  substance  of  the 
right  hemisphere  of  the  cerebellum  was  accidentally  discovered  an  aneu- 
rism about  twice  as  large  as  a  grain  of  wheat ;  it  was  irregularly  fusiform  ; 

Fig.  28. 


Cerebellar  Aneurism.     (Bristowe.) 

its  parietes  were  thickened  and  hardened  with  atheromatous  and  earthy 
deposit,  and  it  gave  off  several  partly  ossified  branches,  each  about  half  a 
line  in  diameter.  Its  anterior  extremity  was  continuous  with  a  thin 
walled  healthy  vessel,  having  between  one-third  and  one-half  the  calibre 
of  the  aneurism  itself,  and  found  to  be  a  branch  of  the  right  superior  cere- 
bellar  artery.  Gouty  indications  were  found  at  different  points. 

Occasional  intracranial  growths  are  the  psammomata  which  are  found 
as  sandy  little  bodies  scattered  over  the  dura  mater,  and  have  a  calcare- 
ous formation,  feel  gritty  when  rubbed  beneath  the  fingers,  and  may  be 
crumbled.  Examined  microscopically  with  a  low  power  they  may  be 
found  to  consist  of  small,  compact,  round  bodies,  imbedded  usually  in  the 
dura  mater. 

Cholesteatoma,  or  pearly  tumors,  which  are  composed  chiefly  of  choles- 
terine,  stearine,  and  degenerated  epithelium  contained  in  an  investing 
membrane,  are  occasionally  present  in  the  brain.  The  latter  growths  are 


1  Trans,  of  Path.  Soc.  of  London,  vol.  x.  p.  4. 


198  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

generally  found  attached  to  the  meninges  or  cranial  bones,  and  are  nearly 
always  superficial. 

The  literature  of  intracranial  bony  growths  contains  much  that  is  inte- 
resting. One  case  reported  by  Vulpian  in  the  Archives  de  Physiologic 
was  remarkable  for  the  slow  development  of  an  exostosis  from  the  temporal 
bone,  which  completely  penetrated  the  Gasserian  ganglia  on  the  right  side. 
Beyond  neuralgia  of  a  severe  character,  no  other  symptoms  were  ex- 
pressed. I  have  seen  many  of  these  bony  growths,  some  of  them  even 
several  inches  in  length,  which  had  existed  for  years  without  any  mischief 
being  produced.  In  slow  growths  there  seems  to  be  an  accommodation 
of  the  brain  so  that  the  pressure  is  rarely  injurious,  and  it  is  generally  not 
till  the  exostosis  attains  some  size,  and  atrophy  or  softening  takes  place, 
that  bad  symptoms  make  their  appearance. 

A  case  which  was  under  the  care  of  Dr.  Janeway  at  the  Epileptic 
Hospital  is  one  of  the  most  remarkable  of  which  I  have  ever  heard,  and  I 
ap|>end  his  very  valuable  record  of  the  post-mortem  examination. 

A.  T.,  aged  42  years  ;  widow  ;  domestic.  Admitted  to  Hospital  De- 
cember 31,  1K72.  Patient  says  that  fourteen  months  ago,  as  she  was 
crossing  the  Jersey  City  ferry,  she  fell  down,  and  heard  the  people  say 
that  some  one  had  had  a  fit.  When  she  came  to,  she  found  that  she 
herself  had  had  a  convulsion.  During  the  attack  she  was  perfectly  con- 
scious of  all  that  passed  about  her,  and,  on  arising  and  attempting  to  tie 
her  bonnet  strings,  she  found  that  she  could  not  do  so  on  account  of  what 
she  says  was  numbness  of  the  hands  or  arms. 

April  21),  1874.  For  the  past  five  days  she  has  been  very  dizzy,  and 
has  had  headache,  and  pain  in  the  left  side  under  the  breast. 

IWth.  Is  in  bed.     Says  "  her  back  feels  as  if  it  was  breaking  in  two." 

May  1.  Is  quite  weak.  Can  move  her  left  leg  somewhat,  but  not  her 
left  arm  ;  her  emotions  are  easily  excited  ;  pulse  weak  :  temperature, 


'2d.  Pulse  good  ;  temperature,  101°. 
3</.  She  lies  with  eyes  half  parted,  and  does  not  open  them  fully  when 
spoken  to.  Pupils  normal  and  respond  to  light.  Answers  questions  in  a 
slow,  whining  tone,  and  with  seeming  difficulty.  Does  not  draw  up  her 
legs  when  told,  but  they  respond  to  reflex  irritation.  The  severe  pain  in 
her  back  still  continues,  and  she  has  some  pain  under  left  breast.  Pain 
on  pressure  in  the  right  iliac  region.  Bowels  free  ;  urine  normal  ;  respi- 
ration normal;  temperature,  100°.  Is  somewhat  stupid;  has  great  pain 
in  back  of  her  head  ;  eyes  half  closed;  conjunctiva  not  very  sensitive; 
passes  urine  and  feces  in  bed. 

\th.  Sleeping;  feces  of  brown  color;  urine  passed  in  bed;  respiration, 

18  ;  pulse,  HH.     P.  M.    Feces  and  urine  passed  in  bed  ;    tongue  dry  and 

coated  brown.     Only  partially  protruded  tongue  when  told  to.     Eyes  half 

closed;  seems  brighter;  respiration,  36;  pulse,  100;  temperature,  102°. 

nth.  Complains  of  pain  in  abdomen  ;  bowels  did  not  move  last  night; 

cries  when  spoken  to  ;  pain  in  back  lighter,  but  in  head  is  sharp.     Pulse, 

iH  ;  temperature,  100°  at  1  1  o'clock  A.  M.     P.  M.  Patient  better;  urine 

highly  colored  ;  no  albumen. 

>M.  Still  pain  at  base  of  skull.     Temperature,  101  1°. 
\'2th.  Temperature,  100J°.     12  M.  Temperature,  99°  ;  headache  not 


so  severe. 


BRAIN    TUMORS.  199 

Jane  '2.  Xo  headache  ;  cries  when  spoken  to. 

dth.  Headache  not  severe ;  pain  in  her  back ;  has  passed  urine  and 
feces  in  bed  for  four  weeks  past. 

M/i.  Temperature,  100±°. 

Wth.  Lies  with  head  turned  to  left.  Complains  of  pain  when  position 
of  head  is  changed.  Headache  is  relieved  by  bromide  of  ammonium. 

19^.  Complains  of  no  pain.  There  appears  complete  muscular  relaxa- 
tion. Cannot  speak  without  crying. 

20th.  Patient  is  rapidly  failing.  Temperature,  103|°;  pulse,  too  rapid 
to  count ;  respiration  very  quick  ;  conjunctiva  insensible  ;  pupils  respond 
slowly  to  light. 

21  st.  This  morning  about  the  same  ;  can  swallow  wine.  P.  M.  Patient 
sank  gradually,  and  died  at  4.30  P.  M. 

Post-mortem  18  hours  after  death Heart,  liver,  lungs,  spleen,  and 

kidneys  normal.  An  abscess  found  in  right  Fallopian  tube  containing 
about  3ij  of  pus.  Rigor  mortis  not  well  marked. 

Skull — On  removing  skullcap,  an  outgrowth  of  bone  is  noticeable  on 
the  right  side,  near  the  central  line,  just  posterior  to  the  groove  for  the 
middle  meningeal  artery.  The  growth  is  nearly  two  inches  long,  and 
one  inch  wide  ;  raised  about  §•  of  an  inch  from  internal  surface.  The  dura 
mater  was  pretty  firmly  attached  at  this  place,  and  little  pieces  were  left 
attached  to  the  exostosis.  There  is  another  bony  projection  (small)  just 
back  of  the  middle  meningeal  artery,  at  the  inferior  angle  of  the  parietal 
bone.  Otherwise  interior  of  skull  appears  normal.  The  lowest  first  (1st) 
is  situated  just  anterior  to  the  fissure  of  Sylvius,  f  inch  below  posteriorly, 
and  |  inch  from  above  downwards.  Elevation,  y£ths  of  an  inch.  This 
has  produced  a  corresponding  depression  and  flattening  of  the  commence- 
ment of  the  lower  end  of  the  transverse  convolution  of  the  anterior  lobe. 
Two  smaller  ones  are  situated  one  just  ^  of  an  inch  above  it,  the  other  1 
inch  above,  and  about  £  anteriorly.  They  are  nearly  half  an  inch  apart, 
the  posterior  being  the  longer,  and  about  T^th  of  an  inch  in  diameter. 
Elevation,  T7^  inch. 

Around  the  first  large  tumor  three  small  ones  exist ;  the  second  small 
one  is  about  one-third  the  size  of  the  first.  A  bridge  of  new  formation 
connects  this  with  the  two  already  described.  At  the  point  of  the  large 
exostosis,  a  number  of  tumors  spring  forth  from  under  surface  of  the  dura 
mater,  close  to  one  another,  averaging  1^  inch  in  diameter.  One  of  these 
tumors  is  quite  large,  and  is  sunk  in  a  depression  in  the  brain ;  the  depth 
is  f  of  an  inch,  and  it  is  an  inch  long  and  broad.  The  brain-tissue  around 
this  is  in  a  state  of  pulpy  softening.  The  diameter  of  the  softened  part  of 
brain  is  two  inches,  and  nearly  reaches  the  longitudinal  fissure,  extending 
two  inches  downwards  to  within  two  inches  of  anterior  border  of  the  brain. 
The  falx  throughout  its  extent  is  the  site  of  new  formations,  some  project- 
ing on  the  right,  others  on  the  left ;  one  very  large  one  in  front,  which  is 
l£  inch  in  length,  and  has  an  elevation  of  || ths  of  an  inch ;  and  another 
which  dips  into  a  depression  in  the  anterior  lobe  of  left  side. 

The  pia  mater  covering  both  hemispheres  is  markedly  congested. 
Tumors  are  firm,  white,  and  yield  only  a  thin  serous  fluid  on  scraping. 

Diagnosis — It  is  a  difficult  matter,  when  we  consider  the  great 
variety  and  irregularity  in  the  appearance  of  symptoms,  to  make  always  a 
correct  diagnosis.  This  branch  of  neurology  is  undoubtedly  the  most 
puzzling,  and  I  am  inclined  to  differ  from  those  persons  who  consider  it 


200  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

]>ossiblc  to  determine  in  the  majority  of  cases  the  exact  location  of  a  cere- 
bral growth.  The  fact  that  brain-tumors  are  very  often  multiple,  and  that 
secondary  lesions  are  produced,  is  enough  to  cool  the  ardor  of  the  most 
enthusiastic  diagnostician.  It  is  possible,  however,  to  sometimes  make  a 
verv  close  diagnosis.  Localized  pain  and  convulsions,  with  optic  neuritis, 
cranial  palsies,  and  vomiting,  suggest  very  strongly  the  probability  of  tumor 
In  speaking  of  the  character  of  the  paralysis,  its  gradual  appearance,  and 
its  limited  Held,  I  have  said  enough  to  demonstrate  that,  generally,  there 
is  no  reason  why  we  should  confuse  this  symptom  with  the  paralysis  of 
softening,  although  softening  may  sometimes  be  secondarily  produced  by 
the  growth,  and  then  there  is  much  more  difficulty  in  deciding  on  the 
nature  of  the  trouble. 

It  behooves  us  to  make,  if  possible,  a  diagnosis  of  the  nature  of  the 
tumor,  and  sometimes  a  very  slight  circumstance  will  suggest  the  real  cha- 
racter of  the  growth. 

The  localization  of  cerebral  tumors  has  received  very  extended  conside- 
ration during  the  past  few  years.  In  the  many  cases  collected  by  Jack- 
son we  are  enabled  to  make  a  much  closer  diagnosis  than  before  his  excel- 
lent investigations  were  presented.  Ogle's  large  number  of  cases  are  more 
of  interest  in  the  light,  of  morbid  anatomy,  and  as  they  are  several  hun- 
dred in  number  almost  every  variety  of  formation  is  to  be  found.  Quite 
recently  an  excellent  article  by  Petrina,  of  Prague,1  has  appeared.  His 
directions  for  localization  are  so  complete  that  I  think  it  wise  to  present 
them,  especially  as  they  are  based  upon  a  number  of  cases. 

I.  Tumors  of  the  Convexity — Clonic  spasms  limited  to  single  groups 
of  muscles  on  the  side  of  the  body  opposite  to  that  of  the  tumor ;  no  loss 
of  consciousness  ;  incomplete  hemiplegia,  constant  headache,  decided  ver- 
tigo, nervous  irritability ;  amblyopia  and  disturbances  of  hearing  ;  circum- 
scrilwd  affection  of  sensibility.    The  localization  of  circumscribed  motorial 
disorders  is  not  definite,  and  can  be  only  limited  at  present  to  the  region 
of  the  anterior  and  posterior  central  convolutions. 

II.  Tumors  of  the  Anterior  Lobes — Frontal  headache;  the  intellectual 
sphere  being  involved  (?,  A.  McL.  H.)  there  will  be  often  psychical  disturb- 
ances, with  chorea ;  paresis  or  hemiplegia  (the  former  more  frequently)  ; 
no  disorders  of  sensibility  ;  general  convulsions  with  loss  of  consciousness 
is  rare,  except  when  there  is  deep  pressure ;  visual  disturbance  and  deaf- 
ness, with  anosmia. 

1 1.  Tumors  of  Parietal  Lobes — Hemiplegia  on  opposite  side  preceded 
frequently  by  apoplectic  attacks;  aphasia  very  frequent  when  tumor  is 
large  enough  to  compress  the  third  frontal  convolution  ;  general  convul- 
sions with  large  tumors ;  disorder  of  special  sense,  except  vision,  quite 
rare  ;  impairment  of  cutaneous  sensibility  common  ;  frontal  headache. 

IV.  Tumors  of  the  Occipital  Lobes — But  one  of  Petrina's  cases  pre- 
sented opposite  sided  paralysis  with  paralysis  of  the  third  nerve  on  the 

1  Viertcljahrsschrift  fuer  die  prakt.  Heilkunde,  cxxxiii.  1.  2. 


BRAIN    TUMORS.  201 

same  side ;  disorders  of  intelligence  ;  convulsions,  involvement  of  organs 
of  special  sense,  cutaneous  derangements  of  sensibility  are  mentioned 
by  Rosentlial  and  others  as  pathognomonic  :  but  are  not  observed  by 
Petrina. 

V.  Tumors  of  the  Motor  Ganglia — Hemiplegia  on  opposite  side,  with 
loss  of  consciousness  and  frequent  convulsions  ;  profound  cutaneous  anaes- 
thesia when  the  internal  capsule  is  destroyed  ;  sometimes  aphasia  ;  corpus 
striatum ;  complete  hemiplegia  with  loss  of  consciousness  and  convulsions ; 
psychic  disorders  and  irritative  motor  phenomena,  such  as  tremor  and  cho- 
roid  movements ;  disorders   of  organs   of  special  sense  are  rare,  with  the 
exception  of  amblyopia. 

VI.  Tumors  of  Optic  Thalamus — Extensive  motorial  symptoms  are 
not  constant, and  general  convulsions  or  disorders  of  sensibility  are  rare. 
"According  as  the  tumor  affects  more  the  bundles  of  fibres  going  to  the 
optic  tracts  or  those  branching  out  from  the  cerebral  peduncle,  we  have 
sometimes  predominating  paralytic  phenomena  in  the  optic  nerve,  altera- 
tions of  the  pupil  and  disturbances  of  the  innervation  of  the  ocular  mus- 
cles  (nystagmus,  exophthalmos)  ;   sometimes,  again,  there  are  the  most 
remarkable  vaso-motor  anomalies  of  circulation   (striking  alterations  of 
temperature,  and  cyanosis,  or  circumscribed  redness),  as  the  chief  morbid 
symptoms.     Pronounced  disorders  of  speech  (retarded  speech)  and  of  the 
intelligence  are  symptomatic  only  of  quite  extensive  tumors  in  the  thala- 
mus ;  decided  paralytic  phenomena  are  likewise  characteristic  of  simulta 
neous  destruction  of  the  peduncular  fibres,  or  of  one  of  the  motor  gan- 
glia." 

VII.  Tumors  in  or  about  the  Pituitary  Body — Somnolence,  mental 
weakness,  or  apathy  ;  slowness  of  speech.     Amblyopia  and  amaurosis  are 
common,  as  well  as  disorders  of  other  organs  of  special  sense.     Rosenthal 
demonstrated  that  diabetes  is  an  important  complication  of  tumor  in  this 
region. 

VIII.  Tumors  of  the  Peduncles  of  the  Cerebrum — Vaso-motor  disor- 
ders and  anomalies  of  temperature  ;  early  paralysis  of  the  third  nerve  on 
the  same  side,  as  tremor,  occasional  vesical  paralysis  ;  opposite  hemiplegia 
with  sensory  disorders ;    intelligence  unimpaired ;    optic  nerve  often  in- 
volved ;  involuntary  movements  of  limbs  on  side  opposite  to  tumor. 

IX.  Tumors  of  the  Crus  Cerebelli — Intense  headache  and  vertigo,  in- 
voluntary lateral  decubitus,  rotation  of  body,  one-sided  deviation  of  axis 
of  vision,  reeling  gait,  and  tendency  to  fall ;  commonly   disturbances   ot 
organs  of  special  sense.     (  Vide  Caton's  Case,  A.  McL.  H.) 

X.  Tumors  of  Cerebellum — Headache  quite  intense,  and  limited  to 
sub-occipital   region,   vertigo,    reeling   gait,    disorders    of    coordination  ; 
paresis  of  opposite  side  of  body ;  convergent  strabismus,  diminished  elec- 
tro-muscular contractility  on  sound  side  of  head. 

XI.  Tumors  of  Pons Cross  hemiplegia  ;  ocular  paralysis  (convergent 

strabismus),  lingual  paralysis  ;  cutaneous  anaesthesia,  double  or  single,  dys- 
phagia ;  disorders  of  special  senses ;  facial  nerve  involved ;  crossed  sen- 


202  DISEASES    OF    THE    CEREBRUM    AND    CEREBELLUM. 

gory  troubles  ;  vaso-motor  disturbances  ;  vertigo  ;  increased  electro-mus- 
cular contractility  of  parts  supplied  by  the  seventh  nerve  to  galvanic  cur- 
rent, but  not  to  faradic  current. 

Greisinger  has  written  quite  fully  upon  the  diagnosis  of  the  character 
of  the  growth.  He  considered  that  convulsion  with  psychical  disturbance, 
but  no  paralysis,  pointed  to  the  presence  of  cysticerci,  because  these  para- 
sites infest  the  uppermost  layers  of  the  cortex  cerebri. 

In  one  of  Jackson's1  cases  (No.  13)  the  signs  of  an  old  iritis  enabled 
him  to  make  a  diagnosis  of  a  gumma.  Other  marks  of  syphilitic  disor- 
der may  be  taken  into  account.  Nodes,  old  scars,  eruptions  of  a  tertiary 
character,  and  alopecia,  as  well  as  numerous  unmistakable  symptoms,  such 
as  rheumatism,  night-sweats,  etc.,  are  confirming  points  in  diagnosis. 
Aneurism,  which  is  rare  in  early  life,  may  be  suggested  by  vertigo  and 
subjective  noises  heard  by  the  patient.  In  the  case  reported  by  Humble 
a  diagnosis  was  made  by  the  stethoscope.  Cancerous  tumors  are  very  dif- 
ficult to  diagnose,  the  age  of  the  patient  being  our  only  guide,  and  we  are 
left  absolutely  in  the  dark  in  regard  to  gliomatous  and  other  non-diathetic 
tumors,  although  some  of  the  German  writers  suggest  that  a  history  of  in- 
jury generally  precedes  the  first  named.  Tubercle  may  be  suspected  after 
a  careful  inquiry  in  regard  to  the  patient's  antecedents,  and  the  recog- 
nition of  the  physical  signs  of  deposit  in  the  lungs.  Parasitic  tumors  are 
generally  attended  by  mental  decay,  and  Hammond'  states  that  epilepti- 
forin  attacks  are  the  first  symptoms  of  such  trouble. 

Prognosis — Cancerous  tumors  prove  fatal  in  from  two  or  three  months 
to  a  year,  while  syphilitic  tumors  are  occasionally  retarded  in  growth,  and 
the  patient  may  ultimately  recover  under  energetic  treatment,  though 
when  left  alone  they  rapidly  increase  in  size.  I  do  not  agree  with  Ham- 
mond in  regard  to  the  chance  of  spontaneous  cure  in  aneurismal  tumors, 
and  feel  disposed  to  consider  any  cases  of  sudden  recovery  as  anomalous. 
The  progress  of  non-diathetic  growths  is  very  slow,  and  the  patient  may 
live  for  many  years,  and  finally  die  of  some  other  disease.  Gliomatous 
tumors  are  perhaps  less  formidable  than  are  others,  but  after  all  more 
depends  upon  the  site  of  the  growth  than  its  size  and  character.  Death  is 
preceded  in  most  instances  by  coma. 

Holmes  says  in  this  connection  :  "  "We  know  nothing  at  present  of  the 
diagnosis  of  intracranial  aneurism,  so  that  no  treatment  can  as  yet  be  di- 
rected gpecially  to  it.  And,  looking  at  the  very  free  intercommunication 
of  the  four  large  trunks  which  nourish  the  brain,  it  seems  unlikely  that 
surgical  measures  directed  to  any  one  of  them  would  procure  the  consoli- 
dation of  an  aneurism  situated  on  one  of  its  main  branches." 

Treatment — It  has  been  my  practice  in  every  case  to  place  the 
patient  upon  an  anti-syphilitic  course  of  treatment.  The  iodide,  in  in- 
ereasing  doses,  until  a  very  large  quantity  is  taken  during  the  day,  will 

1  Medical  Times  and  Gazette,  August  1,  1874. 

2  Diseases  of  the  Nervous  System,  p.  301. 


BRAIN    TUMORS.  203 

sometimes  effect  a  cure.  I  have  given  mercury  also,  but  cannot  speak  so 
favorably  of  its  virtues.  If  the  pain  is  excessive,  I  use  the  ice-bag,  as 
recommended  by  Jackson,  and  find  that  it  gives  great  relief.  Hypodermic 
injections  are  very  useful,  and  hyoscyamus  (F.  71)  and  belladonna  (F.  70) 
also  do  good.  Galvanism  I  believe  to  be  useless.  Ligature  of  the  carotid 
has  been  employed  by  Coe  for  aneurismal  tumors,  and  although  it  was 
successful  in  the  case  he  reports,  I  am  inclined  to  think  it  is  not  only  a 
dangerous  but  an  uncertain  measure. 


204  DISEASES   OF    THE    SPINAL    MENINOES. 


CHAPTER    YIT. 

DISEASES  OF  THE  SPINAL  MENINGES. 
SPINAL  MENINGITIS. 

ACUTE    PACHYMEMXGITIS. 

THE  investing  membranes  of  the  spine  may  be  the  seat  of  chronic  or 
acute  inflammation,  together  or  singly,  though  there  is  generally  a  certain 
amount  of  coexisting  myelitis,  and  consequently  the  meningitis  is  not  an 
uncomplicated  condition.  In  exceptional  cases,  however,  the  dura  mater 
may  be  affected,  and  the  resulting  affection  is  known  as  Spinal  Pachy* 
meningitis  ;  or  the  pia  mater  and  arachnoid  in  other  cases  are  the  seat  of 
such  inflammation  ;  or  the  three  membranes  may  be  together  involved. 

INFLAMMATION    OF    THE    SPINAL    DURA    MATER,  OR    SPINAL 
PACHYMENINGITIS. 

Michaud1  has  given  the  name  external  p  achy  meningitis  to  the  form 
which  results  from  pressure  made  by  diseased  vertebrae,  and  coexisting 
with  Pott's  disease,  while  other  varieties  have  been  described  as  internal 
hemorrhagic  pachymeningitis  (Meyer1)  and  cervical  hypertrophic  pachy- 
meningitis  (Clmrcot1).  The  form  described  by  Meyer  is  almost  identical 
with  that  which  involves  the  cerebral  dura  mater,  and  in  which  there  are 
thickening  and  encysted  clots.  As  the  name  indicates,  the  form  described 
by  Charcot  is  confined  chiefly  to  the  cervical  portion  of  the  spinal  dura 
mater. 

ACUTE    AND    CHRONIC    SPINAL    MENINGITIS. 

Symptoms  —  This  disorder,  which  commonly  involves  all  three  mem- 
branes, is  generally  ushered  in  by  a  chill,  followed  by  elevation  of  tem- 
jR-nittire;  a  hard,  full  pulse;  and  excruciating  pain.  This  pain  is  increased 
by  any  movement  the  patient  may  make.  He  tries  to  relieve  his  suffering 
by  changing  his  |>osition  and  by  keeping  quiet,  so  that  muscular  rigidity, 
which  is  semi-voluntary,  is  often  mistaken  for  a  tetanic  spasm.  Pain 
darting  along  the  spinal  nerves  adds  all  the  more  to  his  misery,  and  his 
legs  are  forcibly  drawn  up.  Hypenesthesia  of  the  surface  is  generally 
present,  and  reflex  excitability  is  nearly  always  exaggerated  in  the  earlier 
stages.  The  head  is  sometimes  drawn  backwards  by  contraction  of  the 


1  Sur  la  MSningiU',  etc.     Thfese,  Paris,  1871. 

2  Di-fl  Paohymeningitide,  etc.     Bonna>,  1861. 

8  Lwjons  sur  les  Fonctions  du  Sys.  Nerveux,  fas.  1,  part  2,  p.  243,  etc. 


SPINAL    MENINGITIS.  205 

post-cervical  muscles,  and  the  appearance  is  presented  which  is  so  well 
marked  in  cerebro-spinal  meningitis.  Should  the  meningitis  be  general, 
or  extend  upwards,  the  intercostal  and  phrenic  nerves  are  finally  involved, 
and  asphyxia  and  death  result.  The  tendency  in  many  cases  is  towards 
chronicity,  and  very  often  there  are  secondary  affections  of  the  cord  from 
pressure.  The  bladder  and  rectum  frequently  suffer  to  such  a  degree  that 
involuntary  discharges  of  urine  and  feces  result,  but  the  former  sometimes 
escapes  the  involvement.  Should  the  disease  become  chronic,  it  exists  in 
a  modified  form,  the  pain  being  less  severe,  and  the  contractions  of  the 
limbs  more  marked.  The  skin  is  cold  and  hyperaesthetic,  and  reflex  exci- 
tability is  present  to  an  extraordinary  degree,  the  slightest  prick  of  a  pin 
being  sufficient  to  cause  violent  retraction  of  the  limbs.  The  muscular 
power  is  greatly  reduced,  so  that  the  individual  may  be  unable  to  take  any 
exercise.  The  bladder  trouble  is  much  more  marked  than  in  the  acute 
variety,  and  the  patient  may  find  it  necessary  to  empty  his  bladder  every 
few  minutes.  Obstinate  constipation,  distension  of  the  bowels  by  wind, 
and  gastric  disturbances,  are  accompaniments.  If  the  cord  is  involved, 
there  may  be  presented  symptoms  of  meningo-myelitis,  and  then  paralysis 
of  motion  and  sensation  becomes  marked,  and  the  muscles  undergo  atrophic 
changes. 

The  case  of  Mr.  J.  E.  is  instructive.  He  is  a  great  sportsman,  and 
up  to  four  or  five  years  ago  was  often  exposed  during  his  hunting  excur- 
sions. Four  years  ago,  during  one  of  these,  he  lay  for  several  hours 
in  a  "battery,"  shooting  ducks.  The  weather  was  cold,  and  he  was 
directly  exposed  to  a  drizzling  rain.  On  the  same  night  he  was  seized 
with  a  chill,  which  lasted  for  nearly  an  hour,  and,  supposing  he  had 
"caught  cold,"  he  drank  altogether  nearly  a  tumblerful  of  whiskey.  Dur- 
ing the  night  he  became  feverish,  complained  of  pain  in  the  back,  vomited, 
and  was  delirious  throughout  the  next  day  and  the  two  following.  His 
pain  was  excruciating,  and  the  slightest  jar  of  the  bed  caused  him  intense 
agony.  At  the  end  of  fourteen  days  he  was  moved  upon  a  mattress  to  the 
nearest  boat,  and  from  thence  to  the  railroad,  and  was  carried  to  his 
home  by  easy  stages.  For  a  month  or  so  after,  he  was  confined  to  his 
bed,  the  pain  gradually  becoming  less  intense,  and  his  strength  returned 
by  degrees.  He  presented  himself  to  me  with  the  history  I  have  just 
detailed.  For  the  past  year  he  has  had  spinal  pain,  which  he  refers  to 
the  last  dorsal  and  upper  lumbar  vertebras.  It  is  constant  and  worse  at 
night,  and  increased  by  pressure.  There  is  gastrodynia,  and  pains  down 
the  back  of  the  thighs,  which  seem  to  increase  after  exercise.  He  com- 
plains of  loss  of  power  in  the  legs,  and  cannot  walk  more  than  a  block  or 
two  without  being  greatly  fatigued,  and  at  night  his  legs  are  jerked  up 
during  sleep.  For  the  past  year  he  has  had  great  distress  and  discomfort, 
as  he  cannot  hold  his  water,  and  is  obliged  to  empty  the  bladder  every 
few  minutes.  His  bowels  are  so  constipated  that  he  finds  it  necessary  to 
use  an  injection  every  night.  Examination  revealed  pain  upon  pressure 
over  the  two  lower  dorsal  vertebra?,  analgesia  and  anaesthesia  of  the  cuta- 
neous surface  of  the  posterior  region  of  thigh.  The  glutei  muscles,  as  well 
as  the  adductors  of  the  thigh,  were  much  reduced  in  size,  and  did  not 
contract  as  powerfully  as  did  those  in  the  neighborhood  when  subjected  to 
electrical  stimulus.  His  abdomen  was  tympanitic  and  greatly  distended. 


206  DISEASES    OF    THE    SPINAL    MEN1NGES. 

He  had  become  desj>ondent  during  the  post  year,  and  neglected  his  busi- 
ness. In  addition  to  the  pain,  loss  of  power,  and  the  other  symptoms  I 
have  enumerated,  there  has  been  a  sense  of  abdominal  constriction  at  the 
level  of  the  painful  point.  Damp  weather  aggravates  the  pain,  and  he  has 
periods  of  improvement,  when  he  goes  to  Florida  or  some  other  warm 
region. 

SPINAL    I'AOHYMENINGITIS. 

Symptoms The  forms  of  pachymeningitis  cannot  be  during  life 

separated  as  a  rule.  There  may  be  no  acute  stage  whatever,  but  a 
gradual  appearance  of  symptoms  indicative  of  slowly  developed  pressure 
upon  the  cord.  The  form  described  by  Charcot1  runs  its  course  in  five  or 
six  years,  and  the  cervical  enlargement  of  the  cord  is  the  part  which  suf- 
fers the  most.  Pressure  is  made  upon  the  cord  itself,  and  upon  the  nerve- 
trunks,  so  that  partial  or  total  loss  of  function  ensues.  There  is  a  painful 
stage,  the  premiere  £&riode  of  Charcot,  which  lasts  several  months,  the 
pain  being  intense  at  the  back  of  the  neck  and  in  the  upper  extremities. 
With  these  pains  there  is  rigidity  of  the  upper  extremities,  and  the  head  is 
drawn  backwards  and  downwards  in  the  manner  I  have  before  described. 
There  are  in  addition  formication  and  disagreeable  sensations  in  the  upper 
extremities,  and  some  paresis,  which  ultimately  increases,  so  that  the  in- 
dividual retains  but  little  power.  Charcot  lias  observed  eruptions  of  bullse 
and  pemphigus  as  evidences  of  lowered  vitality.  After  this  period  there 


I»'-f<>rtnlly  of  Hand  in  Tprvical  Parhymoningiti*  (Charcot). 


is  atrophy  of  the  paralyzed  muscles,  particularly  those  innervated  by  the 
ulnar  and  median  nerves,  while  those  which  are  supplied  by  the  radial 
escape  the  atrophic  change,  and  deformity  often  results  which  somewhat 
resembles  the  main  en  r/rfjfe  of  progressive  muscular  atrophy.  The  pre- 

1  ())..  c-it. 


SPINAL    PACHYMENINGITIS.  207 

ceding  cut  from  Charcot  represents  the  appearance  of  the  hand  in  this 
condition. 

Contractions  of  the  paralyzed  muscles  ultimately  follow  the  paresis,  and 
the  skin  becomes  decidedly  anaesthetic,  so  much  so  that  a  pin  may  be  in- 
serted without  any  expression  of  suffering  from  the  patient.  It  is  very 
rare  for  the  lower  extremities  to  be  implicated,  and  the  medulla  seems  to 
escape  the  effects  of  the  disease,  consequently  troubles  of  deglutition  or 
respiration  are  rare.  The  hemorrhagic  or  internal  form  of  pachymenin- 
gitis  runs  a  most  irregular  course,  but  the  complicating  spinal  affections 
are  apt  to  be  much  more  marked  than  in  the  last-mentioned  variety.  The 
indications  of  internal  pachymeningitis  are  throbbing  pain  in  the  back, 
sudden  paralysis,  and  the  other  symptoms  to  which  I  have  alluded.  The 
disease  is  connected  with  hemorrhages,  and  consequently  there  are  at  inter- 
vals accessions  of  fresh  symptoms. 

The  large  number  of  cases  which  were  known  as  "  syphilitic  para- 
plegia" some  years  ago  include  many  examples  of  chronic  syphilitic 
pachymeningitis,  which  were  then  recognized  as  the  result  only  of  myelitis. 
The  progress  of  the  disease  is  much  more  slow  than  in  other  forms,  and 
the  patient  lasts  a  very  long  time,  and  is  sometimes  quite  cured  by  appro- 
priate antisyphilitic  remedies.  The  acute  zymotic  fevers  are  not  rarely 
followed  by  pachymeningitis,  the  following  case  being  an  interesting 
example  of  this  occasional  sequel  of  typhoid  fever  : — 

Two  years  ago  Capt.  S.  recovered  from  an  attack  of  typhoid,  and  with 
convalescence  he  gradually  lost  power  in  the  right  hand,  right  leg,  left 
leg,  and  left  hand,  in  the  order  I  have  named  them  (this  is  his  statement). 
Preceding  these  conditions  there  were  shooting  pains  running  down  the 
spine  and  around  the  body.  He  was  paraplegic  two  months  afterwards. 
During  this  time  reflex  movements  were  easily  provoked.  "  When  my 
feet  came  in  contact  with  the  foot  of  the  bed,  if  the  cold  wood  touched 
them  they  would  fly  up."  He  evidently  had  the  contractions  which  are 
so  clearly  symptomatic  of  meningitis,  and  there  was  some  constipation,  but 
no  bladder  trouble  except  atony.  His  neck  "felt  stiff,"  and  he  was  occa- 
sionally dizzy.  The  loss  of  power  in  legs  has  gradually  returned. 

Present  condition — The  patient  walks  fairly,  with  no  apparent  impedi- 
ments. The  skin  is  slightly  hypera>sthetic  ;  no  atrophy  of  any  muscles  ; 
has  good  muscular  strength ;  there  is  slight  tenderness  produced  by  pres- 
sure over  the  vertebra?,  between  the  scapulae ;  muscular  tension  at  back  of 
neck,  and  some  pain  with  movement ;  slight  distension  of  abdomen  by 
flatus  (he  says  this  is  a  constant  symptom)  ;  bladder  and  bowels  in  excel- 
lent condition  ;  some  very  trivial  effort  required  to  urinate  ;  no  headache, 
but  dizziness  caused  by  looking  upwards ;  no  loss  of  power  in  hands  or 
arms ;  no  constricting  band ;  patient  can  stand  with  eyes  closed.  Co- 
ordination of  delicate  muscular  acts  unimpaired ;  there  are  no  twitchings 
at  night  left.  I  suggested  the  propriety  of  giving  iodide  of  potassium  in 
addition  to  ergot,  which  he  had  taken  before.  I  also  recommended  the 
actual  cautery. 

Causes — According  to  Grisolle,1  spinal  meningitis  is  much  more 
common  among  men  than  women,  and  three-quarters  of  the  patients  are 


Op.  oit.,  vol.  i.  p.  436. 


208  DISEASES    OF    THE    SPINAL    MENJNQES. 

men  ;  and  Calmiel  considers  it  to  be  of  much  more  frequent  origin  before 
the  thirtieth  year  than  afterwards.  Cold  and  intemperance  favor  its  ap- 
|>earance,  but,  in  the  great  majority  of  cases,  it  is  of  spontaneous  origin, 
and  lias  occurred  in  epidemics,  at  least  so  say  the  earlier  French  writers.1 
In  1837  an  epidemic  appeared  at  London,  Versailles,  Avignon,  Metz,  and 
Strasburg,  and  there  were  no  atmospheric  causes  nor  any  influences  dis- 
covered which  could  account  for  its  appearance.  It  is  probable,  however, 
that  the  form  of  meningitis  was  cerebro-spinal,  with  the  history  of  which 
we  are  now  familiar.  Alcoholic  over-indulgence,  syphilis,  and  injury, 
or  vertebral  disease,  will  account  for  the  affection  in  some  cases.  Like 
locomotor  ataxia  it  very  often  occurs  among  seafaring  men  who  have 
fallen  overboard,  or  have  been  obliged  to  stay  aloft  in  damp,  cold  weather. 
Pott's  disease  has  generally  been  supposed  to  have  little  to  do  with  the 
etiology  of  the  disease,  but  my  own  experience  and  that  of  professional 
friends  who  have  had  much  to  do  witli  this  class  of  cases,  convince  me 
to  the  contrary.  In  a  case  of  this  kind  where  I  was  enabled  to  make  an 
autopsy,  I  found  great  thickening  of  the  spinal  dura,  with  fibrinous  de- 
posits beneath  that  membrane  and  the  bone,  as  well  as  some  involvement 
of  the  nervous  substance  proper,  which  consisted  in  atrophy.  Frac- 
tures of  the  spine,  sometimes  unrecognized,  are  attended  by  so  much 
injury  of  these  membranes  as  to  give  rise  to  symptoms  which  may  be 
either  supposed  to  be  due  to  myelitis  or  simple  concussion,  but  which  are 
undoubtedly  occasioned  by  an  unrecognized  fracture.  Such  a  case  has 
been  reported  by  Mr.  Hutchinson,  in  which  the  individual  jumped  from  a 
height,  alighting  on  his  feet. 

Morbid  Anatomy  and  Pathology The  simple  forms  of  spinal 

meningitis,  that  is  to  say  the  acute  forms,  present  all  the  appearance  of 
violent  inflammatory  action  which  we  witness  in  cerebral  meningitis: 
injection  of  the  pia  mater,  serous  or  purulent  effusions,  together  with 
infiltration  of  adjacent  cellular  tissues,  more  posteriorly  than  anteriorly, 
and  perhaps  some  evidence  of  myelitis,  but  ordinarily  the  cord  is  healthy 
if  the  disease  be  uncomplicated.  The  region  affected  is  more  apt  to  be 
at  tin;  upper  part  of  the  cord,  but  there  may  be  inflammation  of  the  me- 
ninges  covering  the  dorsal  or  lumbar  portions  as  well.  It  may  be  circum- 
scril»ed,  as  the  result  of  pressure  from  displaced  vertebrae,  or  fracture,  and 
this  limitation  is  more  characteristic  of  pachymeningitis.  The  different 
membranes  may  be  adherent  to  each  other,  and  connected  with  the  cellu- 
lar tissue  in  the  vertebral  canal.  New  growths  beneath  the  dura  mater 
are  not  common,  but  may  be  found  sometimes  between  this  membrane 
and  the  bones.  In  cervical  pachymeningitis  there  is  great  thickening, 
ami  in  old  cases  the  nervous  matter  is  compressed  to  such  a  degree  that  it 
is  atrophied,  and  may  be  found  to  be  hardly  two-thirds  its  normal  size.  A 
lamellar  arrangement  of  the  dura  mater  exists,  which  is  like  that  seen  within 
the  cranium,  and  the  other  membranes  may  be  quite  undistinguishable  from 

1  See  articles  in  Meinoires  de  1' Academic  Nationale  de  Med.,  t.  x.,  Revue 
Me  licale,  and  Gaz.  M6dicale,  1842. 


SPINAL  PACHYMEN1NGITIS.  209 

the  dura  mater,  and  consequently  the  cord  will  be  found  encircled  by  an 
almost  homogeneous,  tough,  and  thickened  envelope.  In  the  hemorrhagic 
form,  there  may  be  discovered  encysted  blood-clots  which  resemble  those 
found  in  the  cranial  hemorrhagic  pachymeningitis.  The  nerve-trunks 
within  the  vertebral  canal  will  be  found  to  be  covered  by  the  same  dense 
tissue,  and  the  peripheral  portions  of  the  nerves  are  often  atrophied. 
Syphilitic  inflammatory  changes,  alluded  to  by  Buzzard,1  are  sometimes 
present,  with  gummatous  growths  in  the  nerves  proceeding  from  the  cord. 
The  following  case  illustrates  the  morbid  anatomy  of  meningo-myelitis 
of  a  quite  extensive  character : — 

Idiot;  Chronic  Spinal  Meningitis;  Myelitis;  Lobular  Pneumonia; 
Circumscribed  Acute  Interstitial  Nephritis ;  Chronic  Cystitis — D.  A.,  aet. 
26,  admitted  June  22,  1877.  No  previous  history  of  the  patient  could  be 
obtained,  except  that  she  had  been  an  inmate  of  the  almshouse  for  three 
years  previous  to  admission,  where  she  was  confined  to  bed  entirely.  On 
admission  patient  was  very  much  emaciated ;  legs  and  thighs  flexed.  She 
was  unable  to  talk,  but  almost  continually  screeched,  especially  at  night. 
Two  days  before  her  death  she  had  a  slight  diarrhoea.  On  morning  of 
June  28  had  elevated  temperature,  rapid  pulse,  and  cough.  Chest  could 
not  be  satisfactorily  examined,  as  she  would  not  keep  quiet.  Moist  rales 
were  heard  over  entire  chest.  Patient  became  worse  during  the  day,  and 
died  at  4  o'clock  A.  M.,  June  29,  1877. 

Autopsy  twelve  hours  after  death,  made  by  Dr.  Maxwell,  the  Curator 

Rigor  mortis  present;  body  small,  and  very  much  emaciated;  thighs 
flexed  and  adducted,  and  the  legs  upon  the  thighs,  and  contractured.  Feet 
o?dematous.  Bed-sore  over  sacrum  and  nates.  Fingers  and  thumbs  are 
flexed ;  the  cranium  small ;  round,  low  forehead ;  hair  dark ;  complexion 
brunette ;  eyes  brown. 

Head — Bones :  calvarium  circular ;  antero-posterior  diameter  six  inches ; 
deep  Pacchionian  depression  on  right  side.  Dura  mater  and  sinuses  nor- 
mal. A  little  over  three  ounces  of  fluid  in  subarachnoid  space.  Pia 
mater  over  the  convexity  meshes  is  markedly  elevated  by  oedema,  and  is 
opaque  in  latter  situation  ;  it  is  also  abnormally  adherent  over  convexity, 
and  in  Sylvian  fissure.  Weight  of  brain  and  cerebellum  22  ozs.  Exter- 
nally shows  nothing  except  that  the  sulci  are  wide.  Lateral  A-entricles- 
are  moderately  dilated.  Ependymae  appear  normal.  Cerebellum  weighed 
1^  oz.  Brain -substance  of  cerebrum  and  cerebellum,  gross  appearances 
normal. 

Spinal  Cord — Adhesion  in  cervical  region,  between  dura  mater  and 
wall  of  spinal  canal,  so  firm  as  to  require  section  for  its  removal;  also 
another  point  in  dorsal  region.  Adhesions  between  opposed  surfaces  of 
arachnoid  in  cervical  region  quite  firm  and  general  on  the  posterior  sur- 
face ;  on  anterior  surface  scattered  filaments.  On  posterior  surface  of 
dorsal  region  a  few  filamentous  adhesions.  Dura  mater  in  cervical  region 
is  appreciably  thickened,  especially  the  upper  two  inches.  Pia  mater  cor- 
responding with  these  adhesions  has  brownish  appearance,  and  is  thick- 
ened. Veins  of  cord  are  filled.  Nearly  all  dorsal  portion  of  the  cord  is 
soft  to  the  feel.  Throughout  cervical  region  the  posterior  and  right  lateral 
columns  are  to  the  feel  firm  and  normal ;  have  bluish-gray  color,  with 

1   Syphilitic  Nervous  Affections,  p.  70. 
14 


210  DISEASES    OF    THE    SPINAL    MENINQES. 

yellowish  streaks.  The  dorsal  portion  of  the  whole  cord  markedly  soft- 
ened. Lumbar  region  and  cauda  equina,  to  gross  appearances,  slum- 
nothing  marked.  Dura  mater  surrounding  vertebral  foramina  is  thick- 
ened and  adherent  to  sheaths  of  up|>er  four  or  five  inches  of  cervical 
nerves.  Posterior  long  fissure  of  cord  of  the  dorsal  region  obliterated  by 
firm  adhesions  of  pia  mater. 

TTiorax Lungs  softened ;  on  right  side  adherent.  Pericardium  nor- 
mal. 

Heart  weighs  4  oz. ;  walls,  in  color  and  firmness,  normal.  Cavities 
contained  partially  decolorized  clots.  The  mitral  valve  is  the  seat  of 
chronic  endocarditis.  Chronic  endocarditis  at  commencement  of  aorta. 

Kight  lung — patches  of  fibrinous  exudation  on  pulmonary  pleura  (re- 
cent) ;  lower  lobe  posteriorly.  Lobular  pneumonias  scattered  throughout, 
showing  red  and  gray  hepatization.  On  opposite  lung  only  few  lobular 
pneumonias  in  upper  lobe;  in  lower  lobe,  plentiful.  Both  lungs  markedly 
cedematous ;  small  amount  of  mucus  in  bronchi. 

Peritoneal  Cavity. — Stomach  displaced ;  pylorus  drawn  downward  to 
left,  dilated.  Peritoneum  normal.  Liver  weighs  27  oz. ;  parenchyma 
pale,  otherwise  normal.  There  are  bands  of  adhesion  between  sides  of 
gall-bladder;  hepatic  flexure  of  colon  and  duodenum. 

Spleen  weighs  l£  oz. ;  apparently  normal. 

Kidneys:  each  weighs  l£  oz.  Left  kidney  was  deformed.  Capsules 
of  both  strip  normal.  Surface  of  left  shows  several  large  depressed  cica- 
trices. One  prominent  spot,  yellowish,  of  circumscribed  interstitial 
nephritis.  Cicatrices,  probably  due  to  old  circumscribed  interstitial  ne- 
phritis, seen  from  surface.  Right  kidney  of  normal  shape;  surface  pale 
and  smooth.  Four  nodules  of  acute  interstitial  nephritis  becoming  puru- 
lent are  seen  from  surface.  Pelvis  shows  mild  catarrhal  inflammation. 
Bladder  is  the  seat  of  intense  cystitis. 

Uterus  and  appendages  found  in  a  state  of  retroversion ;  size  corresponds 
with  that  of  other  organs. 

Ovaries  are  large  in  proportion  to  size  of  uterus.  Cysts  in  cortical 
portion,  but  no  corpora  lutea  or  cicatrices  found. 

Stomach  and  intestines  normal. 

Prognosis — The  patient's  chances  are  sometimes  good,  even  in  the 
chronic  form.  Charcot1  has  cured  one  case  of  cervical  pachymeningitis, 
and  doubtless  others  have  been  equally  successful.  In  the  great  number 
of  cases,  however,  a  fatal  termination  is  the  rule.  In  the  acute  form  death 
may  occur  in  six  days,  but  Tourdes  and  Chauffard  have  observed  cases  in 
which  this  termination  did  not  take  place  till  the  fortieth  or  fiftieth  day. 
In  acute  purulent  meningitis  the  pus  may  make  its  way  out,  pointing  ex- 
ternally, or  forming  an  abscess  in  the  muscular  tissue  of  the  back.  Cham- 
pion has  seen  a  case  of  this  kind  in  which  the  purulent  contents  of  the 
vertebral  canal  found  passage  through  at  the  third  lumbar  vertebra,  and 
formed  an  abscess  in  the  spinal  muscles.  This,  however,  is  exceptional. 
When  the  disease  results  from  Pott's  disease,  or  some  other  vertebral 
affection,  it  is  perhaps  possible,  by  mechanical  treatment,  to  improve  or 
cure  the  patient ;  and  syphilitic  forms,  of  course,  are  generally  amenable 

1  Op.  eit. 


SPINAL    PACHYMEMNG1TIS.  211 

to  treatment.     Death  may  occur  from  exhaustion,  and  is  preceded  by  the 
formation  of  bed-sores,  and  evidences  of  a  typhoid  state. 

Diagnosis — It  is  necessary  to  diagnose  spinal  meningitis  of  the  acute 
form  from  myelitis,1  especially  as  these  are  the  only  two  acute  spinal  mala- 
dies beginning  with  fever.  The  pain  is  much  more  severe  in  meningitis, 
and  is  aggravated  by  movement.  The  contractures  and  cramps  are  cha- 
racteristic of  meningitis,  and  are  not  connected  with  uncomplicated  mye- 
litis. Hypenesthesia,  and  exaggerated  reflex  irritability,  and  the  lighter 
grade  of  the  paresis  (there  rarely  being  paraplegia,  and,  if  there  is,  it  is 
quite  late),  are  suggestive  indications  of  meningitis,  which  should  prevent 
any  mistake.  The  chronic  forms  are  of  slow  development,  and  all  the 
symptoms  increase  progressively  after  their  appearance,  the  paralysis  being 
gradual  and  connected  with  contractures  of  the  affected  limbs.  The  para- 
lysis may  not  be  bilateral,  as  is  usually  the  case  in  syphilitic  meningitis, 
and  there  is  rarely  any  extension  of  the  disease  to  a  higher  or  lower  level. 
In  meningitis  there  are  none  of  the  atrophic  tissue  changes  of  the  myelitis, 
but  the  chronic  form  may  so  closely  resemble  chronic  myelitis  as  greatly  to 
puzzle  the  diagnostician.  The  anaesthesia  that  belongs  to  myelitis,  how- 
ever, is  rarely  present  in  meningitis ;  and,  if  it  should  be,  is  a  late  and 
slight  symptom. 

Tetanus  may  possibly  be  mistaken  for  meningitis,  but  such  an  error  in 
diagnosis  should  be  rare,  the  spasms  of  the  former  being  much  more 
general ;  and,  besides,  the  temperature  variations  are  entirely  different,  as 
the  thermometric  rise  in  tetanus  is  unattended  by  any  increase  in  the 
volume  of  the  pulse ;  while  in  acute  meningitis  the  temperature  and  pulse 
are  those  of  an  inflammatory  disease. 

Treatment The  acute  disease  must  be  met  with  energetic  treat- 
ment. Local,  abstraction  of  blood  by  leeches  or  wet  cups  is  the  first  indi- 
cation. Rollet2  has  used  the  cautery  even  in  the  last  stages,  applying  it 
from  the  nucha  to  the  sacrum,  and  with  good  effect.  Chauffard3  has  given 
opium  in  large  doses  in  the  early  stages.  I  prefer,  however,  suppositories 
of  opium  or  belladonna,  which  seem  always  to  relieve  the  pain,  and  are 
attended  by  the  additional  advantage  of  not  deranging  the  stomach. 
Blisters  applied  on  either  side  of  the  vertebral  column,  iodide  of  potassium, 
and  mercurials  (the  former  in  large  doses,  even  to  the  amount  of  a  drachm 
thrice  daily,  beginning,  however,  with  a  minimum  dose),  are  excellent 
remedies.  In  chronic  meningitis  I  have  repeatedly  witnessed  the  benefi- 
cial effects  of  ergot,  and  the  notes  of  the  case  I  present  will  enable  the 
reader  to  appreciate  its  immediate  and  powerful  action  in  a  very  obstinate 
example. 

B.  TV.,  female,  aged  24  years,  single,  domestic ;  admitted  to  hospital 
July,  1875. 

July  6.    The  accession  of  her  trouble  began  about  eight  months  ago, 

1  By  the  use  of  this  term  I  mean  not  only  general  myelitis,  but  those  localized 
forms  known  as  adult  and  infantile  spinal  paralysis. 

2  Memoires  de  1'Acad.  Xat.  de  ]\led.,  xx.  3  Rev.  Med.,  1842. 


212  DISEASES    OF    THE    SPINAL    MENINQES. 

when  severe  pain  in  the  lumbar  region  made  its  appearance.  This  was 
very  intense,  and  seemed  aggravated  by  the  supine  position.  About  ten 
days  after  this  api>eared,  the  abdomen  became  tender,  and  there  w«-n- 
darting  pains  which  extended  about  the  body,  radiating  from  the  spine  ; 
this  abdominal  tenderness  continued  for  two  weeks,  and  then  disappeared. 
She  was  able,  at  the  end  of  a  month,  to  "  go  up  stairs,  and  to  move  about 
the  house."  A  few  weeks  afterwards  she  noticed  a  loss  of  power  in  the 
right  leg  and  thigh,  and  next  in  the  left ;  and,  a  month  later,  she  found  it 
impossible  to  get  out  of  bed  in  the  morning.  She  said  that  her  legs  wen- 
hypera-sthetic,  and  spoke  of  feelings  of  "  pins  and  needles"  in  the  soles  of 
both  feet.  She  says  that  she  thought  her  trouble  arose  from  a  cold  that 
she  had  caught  when  working  in  a  damp  place.  All  this  time  her  pain 
was  quite  intense,  and  there  has  been  no  improvement.  She  has  great 
difficulty  in  micturition,  and  is  constipated. 

2DM.  Painted  iodine  on  either  side  of  the  spine,  and  gave  her  gr.  v 
potass,  iodid.  t.  i.  d. 

Aug.  17.  Her  abdomen  has  been  distended  by  gas  for  the  last  two 
weeks.  Pancreatine  Jss  t.  i.  d.,  and  low  diet. 

'24th.  This  treatment  has  not  diminished  the  size  of  abdomen.  Ordered 
milk,  rice,  and  beef-tea. 

,'iOM.  Lumbar  pain  very  severe.  She  can  hardly  move  at  all,  and  is 
obliged  to  use  crutches.  Injections  of  tr.  assafoctida.  Charcoal  and  water 
fail  to  relieve  the  flatus.  The  abdominal  distension  is  quite  distressing. 

31  st.  To-day  another  injection  of  the  same  kind  did  no  good.  Insom- 
nia and  great  suffering,  as  the  lumbar  pain  is  severe ;  prefers  her  bed, 
and  lies  on  the  left  side.  Chloral  hydrate;  potass,  iodide.  Increased  con- 
vulsive movements  of  legs. 

Oct.  9.  At  times  she  has  localized  pain  over  insteps  of  both  feet,  and 
pain  on  outer  aspect  of  right  knee.  For  the  last  five  days  slight  numb- 
ness as  far  tip  as  her  knees.  Legs  have  "jerked"  less  for  the  last  fort- 
night ;  can  move  well  in  bed  ;  very  slight  power  to  move  right  knee ; 
frequent  desire  to  urinate ;  tympanites ;  some  colic,  pain  less  in  lumbar 
region.  Pulse  12(5,  small  and  irritable;  temperature  101^°.  Blisters 
every  other  night  on  either  side  of  the  spinous  processes. 

'24th.  Abdominal  pain  lessened  ;  can  move  legs  more  freely  ;  numbness 
less. 

Jan.  20,  187<>.  Acidi  nitrorauriat  dil.  has  relieved  constipation,  which 
has  been  a  constant  symptom. 

Felt.  7.  5SS-  fl-  ext-  ergot  t.  i.  d. 

1  {Mh.  Ergot  has  had  wonderful  effect.  Patient  left  her  bed  yesterday, 
and  walked  to  the  front  door  of  hospital  (about  f>0  feet)  and  back  without 
fatigue.  She  steadied  herself  by  taking  hold  of  the  bedsteads.  Has  dis- 
carded her  crutches. 

L>:.M.  Walks  well. 

March  If).  Goes  out  of  hospital. 

April  1 .  Discharged  recovered.  This  patient  was  seen  six  months  after- 
wards, and  she  had  had  no  relapse. 

Ergot  has  acted  equally  well  in  other  cases  which  I  have  treated,  and  I 
am  of  the  opinion  that  it  is  more  valuable  than  any  other  remedy  in  both 
the  acute  and  chronic  varieties  of  spinal  meningitis.  The  actual  cautery 
applied  even-  other  day  should  be  faithfully  used,  and  in  addition  we  may 
employ  setons  at  the  nucha  or  lower  down.  Cod-liver  oil  and  generous 


SPINAL    TUMORS.  213 

diet  are  to  be  prescribed,  and  every  measure  is  to  be  adopted  that  will  in 
any  way  build  up  the  patient.  Should  we  find  vertebral  disease,  a  suita- 
ble brace,  or  the  plaster-jacket  should  be  provided. 


SPINAL  TUMORS. 

The  growth  of  tumors  in  the  spinal  canal  or  cord  is  of  far  less  frequent 
occurrence  than  in  the  cranial  cavity  and  brain,  but  when  tumors  choose 
this  locality  their  presence  is  to  be  much  more  easily  diagnosed. 

The  forms  of  spinal  growths  are  just  as  numerous  as  those  of  the  superior 
part  of  the  cerebro-spinal  axis.  They  may  be  of  any  of  the  varieties  I 
have  named  in  speaking  of  cerebral  tumors,  but  the  kinds  usually  met  with 
are  the  following  : — 

Syphilomata. 

Fibromata,  attached  to  the  meninges,  or  in  the  substance  of  the  cord. 

Tuberculous  (rare). 

Myxomata. 

Sarcomata. 

Parasitic  growths  are  more  rarely  found,  and  the  other  forms  which 
have  been  spoken  of  in  our  consideration  of  brain-tumors  are  equally  uncom- 
mon. Exostoses  give  rise  to  many  obscure,  but  none  the  less  interesting, 
symptoms,  while  sarcomata  are  occasionally  to  be  found  attached  to  the 
inner  surface  of  the  dura  mater  or  other  meninges. 

Spinal  tumors  are  of  slow  growth,  and  of  course  the  appearance  of  symp- 
toms is  consequently  gradual  and  insidious. 

Symptoms. — The  first  indications  are  expressions  of  irritation,  and 
as  a  result  there  will  be  localized  pain,  and  various  disturbances  of  motility 
dependent  upon  the  aberration  of  that  part  of  the  cord  which  is  the  seat 
of  the  tumor.  Our  knowledge  of  physiology  of  the  cord  will  enable  us  to 
appreciate  that  disturbances  in  various  parts  will  be  followed  by  symptoms 
of  pain,1  hyperkinesis,  akinesis,  or  muscular  contractures  expressive  of  in- 
volvement of  the  posterior,  anterior,  or  lateral  columns,  but  there  is  usually 
no  such  possible  localization,  as  the  growth  generally  impinges  upon  large 
tracts  and  works  wholesale  mischief.  Compression  is  followed  by  still 
more  pronounced  symptoms  than  those  attendant  upon  simple  irritation. 
And  there  may  be  complete  paralysis  and  atrophy,  with  muscular  contrac- 
tures of  the  members  either  of  the  upper  or  lower  extremities.  Should 
the  tumor  be  situated  high  up  in  the  cord,  the  muscles  at  the  back  of  the 
neck  may  be  the  seat  of  contractures,  and  those  of  the  face  and  neck  may 
even  suffer;  if  the  tumor  be  seated  lower  down,  the  bladder  and  rectum 
may  also  become  involved,  as  in  some  other  forms  of  spinal  disease. 

Among  the  early  symptoms  may  be  mentioned  the  constricting  band 
which  is  connected  with  neuralgic  pains  that  shoot  down  the  legs.  These 

1  Reynolds  considers  that  pain  in  the  back  is  more  intense  with  carcinoma  than 
with  tubercular  or  other  growths. 


214 

r 


DISEASES    OF    THE    SPINAL    MENINQE8. 


indicate  irritation  of  the  posterior  columns  and  nerve-roots.  Should  the 
anterior  column  and  nerve-roots  be  subjected  to  the  irritating  presence  of 
a  tumor,  the  consequence  of  such  trouble  will  be  convulsive  local  spasm- 
and  increased  reflex  excitability.  Vomiting,  dizziness,  and  pupillary  dila- 
tation are  mentioned  by  Jaccoud  as  evidences  of  tumor  situated  in  the 
cervical  region,  while  nystagmus  and  strabismus  are  also  occasional  ex- 
pressions of  a  growth  so  located. 

The  paralysis  which  follows  increased  pressure  is  not  always  equal,  one 
limb  being  more  feeble  than  another ;  or  there  may  be  hyperkinesis  on 
one  side,  and  paresis  on  the  other. 

Unilateral  irregular  troubles,  both  of  motility  and  sensibility,  are  the  rule. 
There  may  be  anaesthesia  and  analgesia  on  the  side  opposite  the  lesion, 
while  the  paralysis  maybe  the  striking  symptom  on  the  side  of  the  tumor. 
This  may  be  explained  by  the  diagram  of  Radclitfe,  which  I  have  slightly 

Fig.  30. 

MS        S  >f 


modified.  Supposing  that  Fig.  30  represents  a  segment  of  gray  matter, 
we  will  consider  that  S  S'  represent  sensory  fibres  of  a  nerve-root,  and 
M  M  motor  fibres.  The  sensory  fibres  decussate,  S  going  to  one  side  of 
the  body,  while  S'  goes  to  the  other.  M  and  M'  both  leave  the  cord  on 
op|K)site  sides.  A  tumor,  pressing  upon  either  lateral  half  of  the  cord, 
such  as  "  I."  may  simply  paralyze  motion  on  the  same  side,  while  sensa- 
tion remains  unaffected,  and  l>oth  sensation  and  motion  are  intact  on  the 
other.  If  deeper  pressure  is  made,  supposing  "  II  "  to  represent  the 
tumor,  not  only  would  motion  be  paralyzed  on  this  side,  but  sensation  on 
the  other.  If  a, tumor  such  as  u  III"  should  impinge  at  the  decussation 
of  the  sensory  conductor,  we  might  expect  total  abolition  of  sensation  on 


SPINAL    TUMORS.  215 

both  sides,  while  there  would  be  no  paralysis  of  motion.  A  tumor  such 
as  "  IV"  would  paralyze  sensation  on  both  sides,  and  motion  on  one. 

Reflex  excitability  is  ordinarily  increased  in  the  limbs  below  the  lesion, 
but  it  is  stated  that,  when  the  inferior  part  of  the  lumbar  region  or  the 
cauda  equina  are  destroyed,  reflex  excitability  is  abolished  after  a  period 
of  six  days,  and  that  then  the  muscles  begin  to  atrophy.  Jaccoud1  says : 
"  There  is  here  a  new  application  of  the  law  I  have  endeavored  to  make 
clear.  As  long  as  cerebral  influence  only  is  deficient  in  the  inferior  mem- 
bers, the  reflex  and  electric  motility  and  nutrition  of  muscles  are  intact, 
but  when  the  spinal  influence  is  in  default  these  properties  are  abolished." 

A  case  which  during  life  seemed  to  refute  this  assertion  is  the  follow- 
ing, but  after  death  an  additional  tumor  was  found  higher  up,  which  might 
have  suspended  cerebral  influence,  and  still  have  left  a  portion  of  the  cord 
capable  of  giving  rise  to  reflex  movements  when  irritated ;  but  in  some 
respects  the  case  still  renders  what  Jaccoud  has  said  somewhat  doubtful, 
as  the  question  arises  whether  the  larger  tumor  did  not  antedate  the 
smaller,  and  whether  the  original  paraplegia  did  not  take  place  before  the 
growth  of  the  smaller  tumor  destroyed  the  cord.  The  patient  entered  the 
Epileptic  and  Paralytic  Hospital  September  18,  1872,  and  was  examined 
by  Dr.  Janeway,  Dr.  Seguin,  Dr.  Mason,  and  myself,  and  the  very 
thorough  autopsy  was  made  by  Dr.  Maxwell. 

P.  K.,  aged  30  years  ;  occupation,  painter  ;  habits,  intemperate.  Inva- 
sion of  the  disease,  five  years  ago.  Relations  to  other  diseases,  disease  of 
the  spine.  Seat  of  paralysis,  lower  extremities.  Control  of  sphincters, 
very  poor.  Voluntary  movements,  imperfect.  Sensibility,  good.  Speech, 
good.  Hearing,  good. 

Patient  denies  venereal  disease,  and  no  indications  of  it  are  found  on 
examination.  He  states  that  ten  years  ago,  after  an  attack  of  smallpox, 
he  noticed  a  pain  in  the  lumbar  region,  slight  and  irregular  in  occurrence, 

Accompanying  this  pain  he  has  had  frequent  and  uncontrollable  desire 
to  go  to  "  stool,"  and  to  make  water,  but  could  not  do  either  to  his  satis- 
faction. This  all  continued  for  about  five  years,  when  he  noticed  that  he 
was  gradually  losing  control  over  his  lower  extremities,  and  in  five  months 
was  completely  paralyzed. 

Says  the  left  lower  extremity  remained  unaffected  the  longest,  and  in 
a  short  time  this  also  became  as  weak  as  the  right.  Has  no  control  over 
bowels,  and  has  but  little  control  over  the  bladder.  Physical  examination 
reveals  a  slight  degree  of  right  lateral  curvature,  and  a  marked  prominence 
in  lumbar  region,  and  tenderness  on  pressure  at  a  point  corresponding  to 
fifth  lumbar  vertebra.  These  signs  seem  to  point  to  lumbar  abscess,  as 
there  is  slight  fluctuation,  and  the  cachexia  of  patient  is  decidedly  indica- 
tive. 

Both  lower  extremities  are  much  atrophied,  soft,  and  flabby.  Patient 
very  anemic.  Prescribed  iron  and  quinine. 

October  9.  Patient  since  examined  by  Dr.  Seguin,  who  says  the  ab- 
scess is  over  a  point  corresponding  to  upper  third  of  sacrum,  instead  of 
last  lumbar  vertebra,  as  was  first  supposed. 

1  Op.  cit.,  p.  352. 


216  DISEASES   OF    THE    SPINAL    MENINGE8. 

Uth.  At  the  age  of  thirteen  was  struck  in  the  small  of  the  kirk 
with  a  stick.  No  phthisis.  At  beginning  of  trouble  he  had  seviv 
pains  in  tlorsum  of  feet,  with  swelling  and  short  lancinating  pains.  Pains 
in  back  part  of  the  thighs,  in  loins,  and  about  the  sides  of  pelvis.  No 
incontinence  of  feces.  Curvature  began  about  a  year  later  than  the 
commencement  of  paralysis.  When  limbs  were  extended,  they  were 
agitated  by  clonic  spasms,  and  increased  pain  in  feet.  As  paraly>is 
increased  pain  diminished,  although  diminution  was  not  noticed  until 
after  eon  tract  ure.  In  last  two  years  no  material  change  has  taken  place. 
Pain  at  irregular  intervals,  and  occasional  spasms  in  legs  at  night.  Has 
had  from  the  first  a  feeling  of  coldness,  but  never  any  numbness.  Volun- 
tary movements  at  hip-joint  quite  free.  Knees  flexible  at  an  acute  angle. 
Extension  and  flexion  possible  in  both  knee-joints  to  such  an  extent  as 
to  bring  legs  at  right  angles  to  thighs.  Xo  sign  of  voluntary  movement 
below  knee-joints.  Passive  movements  free  at  hip-joints  for  extension, 
which  is  considerably  restrained  at  knee-joints.  Flexion  free,  extension 
beyond  right  angle  hindered  by  tension  of  flexor  muscles  of  thigh.  More 
free  at  ankle-joints  and  toes  ;  the  thighs  are  somewhat  wasted,  but  not 
truly  atrophied.  Left  measures  37-^  centimetres  ;  right,  32  centimetres. 

The  legs  show  extreme  atrophy,  most  marked  on  right  side.  Left  rait' 
measures  23£  centimetres;  right,  21^  centimetres.  The  feet  are  not 
oedematous.  The  integument  over  lower  half  of  tibia  is  apparently  hyper- 
trophied,  feels  elastic,  does  not  pit  on  pressure  ;  the  appearance  as  to  sight 
is  like  that  of  <edcma.  The  bones  do  not  seem  enlarged. 

"When  he  urinates  he  appears  to  empty  bladder  at  once,  but  does  it  with 
difficulty. 

Sensibility  decidedly  lessened  below  knee  ;  slight  impairment  of  feeling 
on  posterior  aspect  of  thighs.  Sensibility  much  impaired  below  knees. 
Impressions  of  pain  are  perceived  less  acutely  than  normal  at  top  of  right 
foot  ;  less  acutely  on  left  foot.  Pricking  not  felt  on  left  toes  ;  slightly  per- 
ceived on  right  toes. 

Claims  to  perceive  pressure  of  hands  on  both  feet.  On  irritating  soles 
of  feet,  slight  involuntary  movements  are  caused  in  thigh  muscles.  Legs 
and  feet  markedly  cold.  On  left  foot  has  ingrowing  nail,  with  ulcerated 
external  matrix.  The  right  toe  was  seat  of  ingrowing  nail,  with  ulcera- 
tion,  some  months  ago.  Lower  limbs  perspire  easily  when  warmed  in 
bed.  Very  feeble  response  to  faradic  current  on  thighs  ;  feeble  reaction 
manifested.  No  response  in  leg  muscles.  Lower  lumbar  region  presents 
a  rounded  tumor,  about  2^  inches  in  diameter,  projecting  about  an  inch, 
and  situated  wholly  over  sacrum.  The  last  two  lumbar  vertebra;  are  un- 
naturally prominent.  Moderate  pressure  produces  no  pain  in  tumor;  has 
been  tender.  Several  large  veins  lie  over  tumor.  Tumor  elastic  to  feel, 
and  gives  an  obscure  deep  fluctuation. 

Deep  pressure  in  left  iliac  region  produces  but  slight  pain.  The  finger 
reaches  a  tumor  deep  in  abdomen.  Examination  by  rectum  shows  a  re- 
laxed sphincter;  the  finger  meets  with  an  apparently  large  promontory  of 
sacrum,  which  is  moderately  elastic  ;  some  fluctuation.  There  is  quite 
surely  a  tumor  involving  the  anterior  surface  of  sacrum.  Pressure  of 
finger  upon  pelvic  tumor  does  not  affect  external  dorsal  tumor. 

Patient  remained  in  the  hospital  for  a  year  after  this,  and  finally  died 
of  exhaustion. 


SPINAL    TUMORS.  217 

Autopsy  thirty-one  hours  after  death.  Rigor  mortis  passing  off.  Ab- 
domen of  greenish  discoloration.  Lower  extremities  contracted.  Left 
foot  slightly  oedematous ;  muscles  of  extensors  atrophied ;  commencing 
decomposition  in  superficial  veins ;  large  bed-sores  over  sacrum. 

Brain P.  M.  decomposition  ;  P.  M.  imbibition  along  vessels. 

Lungs,  Heart,  and  Liver  normal. 

Spleen. — Enlarged  and  softened. 

Kidneys. — Left  enlarged.     Both  show  advanced  P.  M.  changes. 

Stomach  and  Intestines  are  apparently  normal.  The  pelvic  cavity  was 
filled  by  a  moderately  firm,  elastic,  ovoid  tumor,  extending  upward  out  of 
the  pelvis  as  far  as  lower  border  of  third  lumbar  vertebra ;  the  psoas  mus- 
cles flattened,  and  spread  out  over  its  upper  and  outer  border  on  either 
side.  Aorta  and  infra  vena  cava  raised  and  flattened  by  the  upper  end  of 
the  tumor  ;  the  external  iliac  vessels  raised  from  their  normal  situations 
and  course  over  its  lateral  borders.  All  of  above-mentioned  vessels  empty; 
the  ureters  are  over  the  upper  border  of  the  growth,  and  are  tightly 
stretched  and  flattened. 

Bladder  contracted  ;  fundus  raised  out  of  pelvic  cavity ;  muscular  tra- 
beculae  flattened ;  mucous  membrane  pale  around  openings  of  glandular 
follicles. 

Prostate  gland  elongated,  flattened,  and  atrophied  from  pressure. 

Rectum  raised  and  pressed  against  posterior  left  lateral  wall  of  bladder. 
The  growth  had  its  origin  behind  peritoneum. 

The  tumor  has  destroyed  the  whole  sacrum,  except  a  small  piece  of  its 
lower  end,  and  a  few  small  thin  plates,  from  here  and  there,  on  the  surface 
of  its  posterior  attachment  ;  the  fourth  and  fifth  lumbar  vertebrae  were 
wanting,  except  portions  of  laminaa  and  spinous  processes ;  the  body  of 
third  has  in  its  lower  border  a  large  concave  cavity. 

The  tumor  was  also  attached  to  the  lateral  wall  of  the  pelvis;  the 
articular  surfaces  of  the  ilia  eroded ;  the  right  most  destroyed.  During 
its  removal  large  cavities  were  opened,  from  which  a  thin,  yellowish,  viscid 
fluid  escaped,  more  or  less  colored  with  blood.  Aftei;  removal,  the  tumor, 
with  bladder,  prostate,  and  portions  of  rectum,  weighed  five  pounds;  mea- 
sured in  long  diameter  twelve  inches,  transverse  six  to  seven  inches.  In 
laying  it  open  on  posterior  attached  surface,  the  tumor  is  composed  of 
large  trabeculre  and  solid  portions  inclosing  areola,  which  contained  the 
fluid  above  mentioned. 

The  surface  of  the  trabeculae  was  covered  with  small  and  large  villi, 
projecting  into  the  cysts ;  the  general  color  was  yellowish  or  yellowish- 
brown  ;  in  certain  portions  hemorrhagic.  These  hemorrhagic  patches  are 
softer  than  the  yellow  "  consistency,"  and  there  were  solid  portions,  where 
it  was  quite  firm.  Microscopic  examination  showed  the  histological  struc- 
ture of  the  tumor  to  be  a  myxo-fibroma-cavernosum. 

Spinal  Cord A  small  secondary  tumor,  about  two  inches  above  its 

lower  end  on  left  side,  behind  origin  of  anterior  roots  of  spinal  nerves. 
This  tumor  is  about  three-quarters  of  an  inch  by  half  an  inch  wide,  ovoid, 
reddish,  and  shining,  gelatinous,  and  attached  to  the  "  pia  mater."  The 
cauda  equina  has  been  destroyed,  except  a  short  portion  of  the  origin  of 
the  nerves  composing  it ;  the  whole  cord,  but  especially  the  anterior  half 
below  cervical  portion,  softened,  presenting  numerous  varicosities. 

Causes. — The  existence  of  the  tubercular  or  syphilitic  cachexia,  the 
indications  of  former  or  coexisting  syphilitic  symptoms,  and  the  history  of 


218  PI8HA8ES    OF    THE    SPINAL    MENINGE8. 

the  patient,  may  throw  some  light  upon  the  spinal  condition;  but,  after  :ill, 
we  know  very  little  al>oul  the  etiology  of  spinal  or  other  tumors.  Spinal 
growths  am  rarely  found,  except  in  adult  life. 

Morbid  Anatomy  and  Pathology. — Syphilitic  deposits  are  found 
in  the  spinal  substance  between  the  meninges  and  about  the  nerve-roots. 
The  exudation  resembles  that  found  in  the  brain  and  other  organs.  The 
site  of  these  deposits  is  chiefly  about  the  circumference  of  the  cord,  and  is 
rarely  central.  Tubercular  deposits  may  affect  the  entire  cord  and  its 
covering,  but  have  been  met  with  in  the  majority  of  instances  in  the  gray 
matter.  Jaccoud  says  that  they  are  nearly  always  found  in  the  gray  mut- 
ter of  the  lumbar  enlargement.  Tubercles  may  be  found  coexisting  in 
the  cord  and  brain.  Myxoma  are  found  in  the  cord  much  more  often  than 
in  the  brain,  and  are  attended  by  separation  of  the  nerve-fibres  and  great 
mechanical  destruction.  Cancerous  growths  may  and  usually  do  spring 
from  the  vertebra;,  and  are  of  a  fungoid  character.  Secondary  degenera- 
tions are  to  be  found  in  certain  cases,  as  well  as  aneurisms,  organized  clots, 
cysts,  and  other  evidences  of  previous  disease. 

Diagnosis. — It  is  not  an  easy  matter  to  distinguish  the  symptoms 
which  attend  spinal  tumor  from  those  of  some  of  the  other  spinal  diseases. 
"We  should  bear  in  mind,  however,  that  the  indications  are  slowly  ex- 
pressed ;  that  the  paralysis  is  irregular ;  that  one  group  of  muscles  may 
be  affected  at  first,  and  then  others ;  that  the  degree  of  lost  power  is  not 
the  same  on  both  sides  of  the  body  ;  and,  also,  that  perverted  sensation 
is  not  the  same  over  the  two  sides  ;  that,  usually,  there  are  contractures 
of  the  limbs  which  need  not  be  preceded  by  atrophy ;  and,  finally,  that 
pain  is  a  symptom  which  is  very  constant. 

Prognosis — I  have  never  witnessed  a  recovery  from  spinal  tumor 
unless  the  character  of  the  growth  was  syphilitic,  and  doubt  very  much 
whether  a  cure  has  ever  been  effected.  It  is  impossible  to  limit  the  dura- 
tion of  disease  which  depends  so  much  upon  the  character  of  the  morbid 
growth.  Patients  may  last  for  eight  or  ten  years ;  or,  on  the  other  hand, 
they  may  live  a  very  short  time,  should  the  tumor  be  cancerous.  Death 
usually  occurs  by  pneumonia,  uraemia,  or  some  debilitating  disease. 

Treatment If  syphilis  be  suspected,  we  are  to  give  very  large 

doses  of  the  iodide  of  |K>tassium  ;  or,  we  may  administer  the  biniodide  of 
mercury  in  combination  with  this  salt.  In  other  states,  supportive  treat- 
ment or  counter-irritation  offers  a  feeble  hope  of  relief. 

SPINAL  HEMORRHAGE. 

MKNIX(;EAL;    CRXTKAL. 

Synonyms — lla-matorrhachis  ;  htematemyllie  (Ollivier).  Spinal 
apoplexy. 

tender  this  head  we  may  consider  the  effusion  of  blood  into  the  spaces 
between  or  under  the  meninges  of  the  cord,  and  the  effusion  of  blood  into 
the  substance  of  the  cord  itself. 


SPINAL    HEMORRHAGE.         '  219 

Symptoms. — Very  often  the  first  intimation  of  the  rupture  is  a  sudden 
loss  of  power,  and  consequent  inability  of  the  individual  to  stand.  It  may, 
on  the  other  hand,  be  of  gradual  development,  the  symptoms  appearing  in 
groups,  one  after  the  other.  The  resulting  paralysis  is  generally  complete, 
and  the  patient  loses  both  motor  power  and  sensibility,  as  well  as  control 
over  the  bladder  and  bowels,  accompanied  by  a  number  of  slowly-developed 
symptoms,  with  diminution  of  reflex  excitability,  although  the  latter  may 
be  exaggerated  in  some  cases  should  the  hemorrhage  be  small  and  between 
the  meninges.  The  abolition  of  muscular  power  may  vary  in  proportion 
to  the  gravity  of  the  hemorrhage,  and  if  it  be  small  the  patient  may  ulti- 
mately recover,  and  eventually  present  no  indications  of  his  loss  of  power. 
I  have  never  seen  a  fatal  termination  before  the  end  of  several  days,  and 
doubt  if  such  could  be  the  case  unless  the  hemorrhage  should  occur  at  a 
very  high  point,  involving  a  number  of  the  intercostal  nerve-roots  ;  but 
even  this  is  improbable,  although  Hammond  takes  an  opposite  view.  Ot 
course  much  depends  upon  the  site  of  the  ruptured  vessel.  If  the  upper 
part  of  the  cord  or  the  medulla  be  affected,  then  an  immediate  and  fatal 
termination  is  a  natural  result.  Meningeal  hemorrhage  is  characterized  by 
more  pronoun.ced  symptoms  of  muscular  rigidity,  or  by  convulsions,  which 
may  be  of  a  tetanic  character.  If  the  hemorrhage  has  taken  place  above 
the  fourth  or  fifth  dorsal  vertebra,  it  is  common  to  find  obstinate  pria- 
pism  and  intestinal  disturbances,  giving  rise  to  flatus,  these  resulting 
from  paralysis  of  the  splanchnics;  if  it  be  extensive,  there  may  be  para- 
lysis of  motion  and  sensation  from  pressure  exerted  upon  the  cord,  and 
pain  and  spinal  tenderness  are  also  quite  marked  symptoms,  and  in  un- 
complicated cases  there  is  cutaneous  hyperaesthesia.  There  is  commonly 
no  loss  of  consciousness  in  either  variety,  but  when  the  effusion  takes 
place  in  the  medulla  there  may  be  conditions  akin  to  epilepsy.  In  this 
case,  however,  effusion  would  be  very  small,  and  the  region  affected  would 
be  near  the  circumference. 

Causes — Spinal  hemorrhage  is  usually  the  result  of  a  traumatism,  but 
may  proceed  from  various  debilitating  diseases  and  some  of  the  zymotici, 
smallpox  playing  occasionally  a  part  in  the  etiology.  Alcoholism,  and  other 
conditions  in  which  the  cord  is  congested,  may  predispose;  or  the  hemor- 
rhage may  result  from  the  rupture  of  an  aneurism  in  the  vertebral  canal,  such 
as  occurred  in  Laennec's  case.  It  very  rarely  takes  place  as  a  secondary 
accident  in  tetanus,  so  that  it  can  be  recognized  before  death  ;  but  at  the 
post-mortem  examination  such  pathological  evidences  may  be  occasionally 
observed.  Traumatisms  undoubtedly  most  frequently  produce  this  condi- 
tion ;  and  falls,  blows  upon  the  back,  or  concussion  following  a  fall  upon 
the  feet,  enter  into  the  etiology.  It  may  occur  in  the  course  of  myelitis, 
but  again  it  may  happen  without  any  trace  of  inflammatory  trouble  to  be 
discovered  after  death  ;  and,  in  some  instances,  there  is  no  history  of  in- 
jury. Such  a  case  undoubtedly  resulted  from  sudden  congestion  at  the 
menstrual  period,  and  is  reported  by  Goldammer1 : — 


1  Virchow's  Archiv,  Jan.  1876,  and  Abstract  Medical  News. 


220  DISEASES    OF    THE    SPINAL    MENINGES. 

"  The  patient,  a  girl  of  about  sixteen  years,  was  suddenly  attacked  with  u 
severe  pain  in  her  back  between  her  shoulders,  which  soon  passed  over  to 
her  right,  and  after  a  while  to  her  left  arm.  She  also  noticed  a  pain  in 
the  pit  of  her  stomach,  and  found  somewhat  later  that  she  could  not  move 
her  right  leg.  Having  been  sent  to  the  hospital,  the  examining  physician 
found  complete  paraplegia,  complete  anaesthesia  up  to  the  mamilhv,  and 
paralysis  of  the  bladder,  while  the  reflex  action  of  the  lower  extremities 
was  still  intact ;  her  temperature  was  normal,  pulse  80 ;  did  not  show  any 
brain  symptoms,  but  complained  of  pain  in  both  arms.  A  few  days  after- 
wards the  abdominal  and  dorsal  muscles  proved  to  be  paralyzed,  and  per- 
cussion of  the  spinous  processes  of  the  dorsal  vertebra?  caused  her  pain.  The 
pulse  was  DC  ;  her  bowels  moved  only  when  drastics  were  given  her.  A 
slimy  discharge  from  her  vagina  was  noticed.  The  case  was  considered 
as  hemorrhage  into  the  spinal  cord  below  its  cervical  enlargement.  The 
treatment  consisted  in  local  depletion,  in  the  methodical  use  of  the  oint- 
ment of  mercury,  and  in  the  Use  of  drastics.  The  patient,  having  im- 
proved in  general  very  little,  died  from  decubitus  about  a  year  after  the 
attack.  The  most  noteworthy  observations  made  on  autopsy  are  the 
following :  About  one  inch  below  the  cervical  enlargement  of  the  spinal 
cord  there  seemed  to  be  a  compressure.  A  cross  section  through  this 
part  showed  that  its  original  diameter  was  reduced  very  much,  and 
that  the  right  lateral  column  and  the  adjacent  parts  of  the  anterior  and 
posterior  columns,  as  well  as  the  gray  substance  between,  were  occupied 
by  a  rusty  brown  substance  of  callous  consistence.  The  microscopic  ex- 
amination of  this  proved  that  it  was  formed  of  connective  tissiie  inclosing 
tatty  matter,  crystals  of  tuematoidine  and  a  granulated  brownish  pigment; 
the  vessels  in  this  part  had  undergone  fatty  degeneration,  their  walls  were 
thickened,  and  contained  brown  pigment ;  no  nervous  elements  could  be 
found  in  this  substance  ;  its  entire  length  was  about  one-tenth  of  an  inch. 
The  adjacent  parts  of  the  medulla  were  not  degenerated  by  softening;  only 
a  few  rusty  stripes  and  a  yellowish  color  were  noticed  on  their  examina- 
tion ;  the  whole  remaining  cord  was  found  to  be  intact.  As  no  symptom 
speaks  for  myelitis  as  a  causal  element  in  this  disease,  it  could  only  be 
caused  by  an  effusion  of  blood  into  the  substance  of  the  cord :  the  latter 
probably  had  been  provoked  by  suppression  of  the  menses,  for  the  heart 
iind  the  vessels,  especially  those  of  the  spinal  marrow,  were  intact,  and  no 
injury  had  occurred  to  the  patient,  It  is  true  that  she  stated  she  never 
had  had  her  catamenia  nor  noticed  any  molimina,  in  spite  of  her  age  and 
bodily  development.  There  were,  also,  no  signs  of  menstruation  noticed 
during  her  sickness.  But  there  was  revealed  by  autopsy  the  presence  of 
a  corpus  liiteum  of  the  size  of  a  pea,  and  certainly  of  a  longer  standing; 
and  a  slimy  excretion  from  her  vagina  was  observed  a  few  days  after  the 
attack.  These  facts  favor  strongly  the  above-mentioned  suggestion." 

Morbid  Anatomy — Central :  hemorrhage  takes  place  into  the  upper 
part  of  the  cord  more  often  than  in  any  other  locality,  but  the  lumbar  and 
dorsal  segments  may  also  be  its  seat.  The  gray  matter  is  naturally  more 
frequently  the  seat  of  hemorrhage  than  the  white,  and  when  preceded  by 
myelitis  or  injury  it  will  be  generally  more  extensive  than  in  the  latter. 
If  the  hemorrhage  be  profuse,  we  will  find  that  the  cord  is  enlarged  at  the 
point  where  the  escape  of  blood  has  taken  place,  and  that  it  has  a  doughy 
feel.  Hemorrhage  into  the  meninges  may  be  sometimes  associated  with 


SPINAL    HEMORRHAGE.  221 

an  intracranial  condition,  the  blood  escaping  from  a  cerebral  vessel,  flood- 
ing the  ventricles,  and  passing  down  into  the  spinal  cavity.  Various 
meningeal  diseases  may  terminate  in  this  way,  as  well  as  spinal  congestion 
and  tetanus,  and  occasionally  spinal  tumors  and  vertebral  disease  give  rise 
to  such  an  effusion  of  blood.  Old  cysts  have  been  found  in  the  cord  in 
some  cases,  but  their  existence  is  comparatively  rare,  and  when  met  with 
they  present  the  same  appearance  as  is  seen  in  the  brain,  though  of  course 
they  are  much  smaller.  In  meningeal  hemorrhage,  the  coverings  of  the 
cord  are  red  and  suffused,  and  perhaps  opalescent  and  thickened,  and 
there  is  possibly  some  meningitis  with  sero-purulent  collection ;  the  effused 
blood  may  be  found  as  a  semi -organized  clot,  and  presents,  according  to 
the  time  of  existence,  changes  of  color  of  varying  depth.  Occasionally 
the  condition  which  favors  the  development  of  spinal  apoplexy  may  lead 
to  cerebral  accidents  of  the  same  character,  and  evidences  of  such  trouble 
may  be  found  to  coexist. 

Diagnosis The  symptoms  must  be  distinguished  from  paraplegia  due 

to  myelitis,  and  from  those  of  cerebral  hemorrhage,  which  may,  as  Brown- 
Sequard  has  lately  shown,  be  produced.  In  the  former  there  are  primary 
symptoms  which  I  will  discuss  in  speaking  of  myelitis,  and  in  the  latter 
there  is  usually  some  affection  of  consciousness,  and  some  disturbance  of 
speech.  This  latter  variety  of  disease  (cerebral  paraplegia)  is  so  anoma- 
lous, however,  as  to  have  but  little  weight  as  a  condition  to  be  excluded. 
The  subsequent  effects  of  such  a  hemorrhage,  paralysis,  contractures,  etc., 
may  be  confounded  with  several  chronic  conditions.  Among  these  are 
spinal  tumors,  adult  spinal  paralysis,  and  ataxia.  The  first  is  connected 
with  decided  hyperkinesis,  is  of  gradual  development,  and  is  accompanied 
by  slowly  appearing  symptoms.  Antero-spinal  paralysis  or  adult  spinal 
paralysis  is  ushered  in  by  fever  and  unattended  by  any  loss  of  sensation 
or  incontinence,  and  the  atrophy  is  rapid.  Locomotor  ataxia  is  symptom- 
atized  by  increased  electric  contractility,  by  no  paralysis,  and  by  disturb- 
ance of  coordination. 

Prognosis If  the  hemorrhage  takes  place  in  the  meninges  or  in  the 

lower  pa£t  of  the  cord,  the  prognosis  is  perhaps  better  than  if  its  seat  is 
in  the  cervical  or  dorsal  segments.  In  the  first  instance  the  patient  may 
live  some  time  or  ultimately  recover,  but  in  the  latter  the  probability  of 
sudden  or  early  death  is  almost  certain.  Grisolle1  says :  "  Spinal  hem- 
orrhage runs  a  rapid  course.  A  single  patient  has  survived  forty  days ; 
the  majority,  however,  succumb  at  the  end  of  several  days,  by  suspension 
of  respiration.  Among  others  death  is  hastened  or  produced  by  the  devel- 
opment of  bedsores.  Nevertheless,  spinal  hemorrhage  is  not  necessarily  a 
fatal  condition."  He  refers  to  a  case  observed  by  Cruveilhier,  and  states 
that  this  is  the  only  cure  of  which  he  has  known.  Erichsen,2  however, 


1  Grisolle,  Path.  Interne,  vol.  i.  p.  659. 

2  On  Concussion  of  the  Spine,  etc. 


222  DISEASES    OF    THE    SPINAL    MENINOE8. 

has  reported  recoveries  which  have  taken  place  in  cases  which  were  of 
traumatic  orijrin;  so  the  prognosis  is  |>erhaps  not  so  bud,  after  ;ill. 

Treatment The  early  treatment  of  spinal  hemorrhage  should  con- 
sist of  cold  applications  to  the  spine,  perfect  quiet,  and  rest.  Subsequently 
ergot  and  belladonna  will  be  of  great  benefit.  Blistering  and  leeches  to 
the  painful  point  in  the  back  are  next  in  order,  and  later  on  the  actual 
cautery  is  the  most  serviceable  external  agent. 


SPINAL    HYPER^MIA  223 


CHAPTER   Will'. 

DISEASES  OF  THE  SPINAL  CORD. 
SPINAL  HYPERjEMIA. 

(A)   SPINAL  CONGESTION  ;    (B)   SUBACUTE  SPINAL    HYPERvEMIA. 

Two  varieties  of  spinal  hypertemia  exist:  one  of  sudden  origin,  and  of 
a  sthenic  character,  which  I  prefer  to  call  Spinal  Congestion;  the  other 
of  slow  progress  as  compared  to  the  first,  and  characterized  by  accumula- 
tion rather  than  congestion,  which  I  will  speak  of  as  Subacute  Spinal 
Jfypercemia. 

SPINAL  CONGESTION. 

This  first  variety,  which  has  been  excellently  described  by  Badclife,1  is 
not  so  common  as  the  latter,  or  at  least  such  has  been  my  experience.  It 
is  apparently  a  serious  condition,  and  may  somewhat  puzzle  the  incautious 
observer  who  may  mistake  it  for  some  one  of  the  organic  diseases;  but  it 
has  certain  distinct  features  which  do  not  belong  to  the  organic  neuroses, 
and  I  think  there  should  be  no  difficulty  in  making  a  diagnosis. 

Symptoms — The  following  may  be  the  symptoms  of  an  attack  of 
Spinal  Congestion.  The  patient  probably  attracts  the  notice  of  his  friends 
by  telling  them  that  he  cannot  get  out  of  bed,  that  "  he  feels  as  if  he  were 
a  lump  of  lead,"  or  that  his  "  legs  and  arms  are  made  of  wood."  He  can- 
hot  move,  and  complains  repeatedly  of  his  utter  weakness ;  he  sighs,  and 
may  complain  that  the  room  is  close,  and  ask  to  have  a  window  opened; 
he  is  able  to  appreciate  any  warm  substances  that  may  be  applied  to 
the  surface,  and  very  acutely  feels  pinching  or  the  prick  of  a  pin.  The 
legs,  he  says,  seem  very  cold,  and  he  requires  extra  covering ;  he  has 
backache  and  pains,  which  run  down  the  back  of  the  thighs,  but  pressure 
does  not  aggravate  the  pain  in  the  back,  which  is  only  relieved  by  lying 
upon  the  side  or  belly.  His  mind  is  clear,  but  he  is  restless,  suffers  for 
want  of  sleep,  and  is  extremely  uncomfortable.  The  functions  of  the 
bowels  are  perhaps  interfered  with,  there  being  constipation;  but  there  is 
never  incontinence  of  urine  or  feces.  The  patient  becomes  paralyzed,  and 
such  paralysis  is  rather  sudden,  and  may  take  place  during  the  night,  or 
perhaps  more  gradually  after  the  appearance  of  pain  and  the  other  symp- 
toms just  mentioned.  Reflex  action  is  abolished,  and  electro-muscular 
contractility  is  increased. 


1   Article  in  Reynokls's  System  of  Medicine,  vol.  ii. 


224  DISEASES    OF    THE    SPINAL    CORD. 

Kadclitfe  calls  attention  to  the  wasting  of  the  muscles,  but  I  have  never 
seen  more  than  the  general  atrophy  which  would  occur  from  disease  of  the 
lower  extremities,  for  the  patient  may  sometimes  lie  in  bed  for  months 
before  he  regains  the  lost  power.  The  duration  of  the  attack  rarely 
exceeds  six  weeks,  but  there  is  a  possibility  of  a  second  attack.  Tlic 
paralysis  is  generally  paraplegic,  though  it  may  be  irregular  in  its  onset, 
one  leg  or  arm  being  affected  before  the  other,  and  in  some  cases  it  i> 
general.  The  spinal  pain  seems  to  be  increased  by  warmth,  and  tin- 
patient  will  feel  the  ice-bag  to  be  very  grateful  after  lying  upon  his  back 
for  a  long  time  on  a  warm  bed.  These  pains  are  as  a  rule  unaffected  by 
movement,  which  is  not  the  case  in  meningitis.  I  have  never  seen  bed- 
sores as  a  feature  of  the  disease,  and  for  this  reason  no  suspicion  of  mye- 
litis should  arise. 

SfBACUTE  SPINAL  HYPER^MIA. 

Symptoms — The  expressions  of  this  condition  are  very  slowly  mani- 
fested, and  are  very  often  mistaken  for  those  of  the  opposite  condition — 
nnuMnia  of  the  cord.  Tingling  and  heaviness  of  the  limbs  may  distress 
the  patient,  and  render  him  disinclined  to  take  exercise  or  remain  stand- 
ing for  any  length  of  time,  and  much  of  his  want  of  energy  may  be  mis- 
taken for  laziness.  These  symptoms  are  especially  disagreeable  towards 
night  in  those  who  have  walked  much  during  the  day,  and  there  is  an 
uneasy,  tired  feeling,  which  is  only  relieved  by  change  of  position ;  and 
the  patient  seeks  in  vain  for  a  comfortable  place  to  rest  his  weary  limbs,  and 
only  finds  it  when  he  lies  upon  his  bed  or  sofa.  There  may  be  cutaneous 
anaesthesia,  and  occasionally  hypenesthesia,  but  these  sensory  troubles 
are  by  no  means  common.  There  may  also  be  the  "constricting  band," 
which  is  so  usually  suggestive  of  inflammation,  and  there  are  vague 
undefined  pains  in  the  thighs,  legs,  and  back,  which  are  extremely  dis- 
tressing. The  temperature  is  lowered,  and  there  may  be  the  same  op- 
pressed breathing  which  is  such  a  marked  feature  of  the  acute  variety. 
Decided  paresis  is  rare,  and,  if  it  should  take  place,  it  is  nearly  always  para- 
plegifonn,  and  not  general,  as  it  may  occasionally  be  in  the  acute  variety. 
Should  this  be  the  case,  we  will  find  the  same  impaired  condition  of  reflex 
excitability  and  normal  electro-muscular  contractility  which  characterizes 
the  more  active  variety  of  spinal  hypera-mia.  The  tendency  of  the  disease 
is  to  disappear  under  proper  treatment,  and  in  its  worst  forms  is  neither  a 
grave  nor  lasting  trouble,  and  should  not  be  looked  upon  with  alarm. 

Causes — Women  seem  to  be  more  subject  to  the  first  form  than 
men,  and  this  is  probably  owing  to  irregularities  of  the  menstrual  condi- 
tion. Uterine  conditions,  symptomatized  by  dysmenorrluca  or  amenor- 
rh(i-a,  may  be,  and  often  are,  its  sole  causes.  Among  men,  the  long  con- 
tinuance of  the  erect  position  seems  to  favor  the  gravitation  of  blood,  and 
hypostatic  hypenemia  of  the  spine  is  thereby  induced.  A  few  years  ago 
I  satisfied  myself  that  the  maintenance  of  the  erect  posture  for  a  long-con- 
tinued period  resulted  in  a  great  deal  of  mischief.  My  investigations 


SPINAL    HYPERAEMIA.  225 

were  much  among  car-drivers,  who  were  compelled  to  stand  upon  the  platform 
of  the  city  railroad  cars  for  a  period  of  from  fourteen  to  sixteen  hours  daily. 
Spinal  congestion,  varicose  veins,  and  other  vascular  changes  were  common 
and  serious  results ;  and  the  spinal  troubles  were  only  relieved  by  a  long  rest. 
Venery,  alcoholic  intemperance,  and  malaria  are  often  causes  of  spinal 
hypenvmia;  and  suppression  of  any  bloody  discharge,  such  as  the  menses, 
or  that  from  haemorrhoids,  will  be  apt  to  be  followed  by  more  or  less 
spinal  hyperaemia.  Among  the  more  serious  causes  of  spinal  hyperaemia 
may  be  mentioned  the  fevers.  The  spinal  congestions  which  usher  in 
some  of  the  exanthemata  are  symptomatized  by  back  pains,  etc.,  and  do 
not  properly  come  under  this  head  for  discussion ;  but  there  are  conditions 
which  play  a  most  important  part  in  the  etiology  of  spinal  congestion. 
The  malarial  cachexia  very  frequently  induces  a  condition  of  spinal 
hyperaemia  which  misleads  the  observer,  and  the  true  cause  may  be  lost 
sight  of  under  the  periodic  character  of  the  painful  exacerbations.  This 
we  should  take  into  account  if  there  be  any  suspicion  of  malarial  poison- 
ing. I  have  seen  many  cases  of  very  decided  subacute  spinal  hyperaemia 
which  followed  intermittent  fever.  The  disease  had  become  masked  to 
some  degree,  so  that  no  chill  was  complained  of;  but  the  individual  suf- 
fered more  at  some  parts  of  the  day  than  at  others,  and,  in  one  case  of 
this  kind,  there  was  some  loss  of  powder,  which  was  increased  daily  at  a 
certain  hour,  and  never  seemed  to  disappear  entirely. 

Morbid  Anatomy  and  Pathology. — "What  I  have  said  in  speak- 
ing of  cerebral  hyperaemia  may  be  referred  to  in  explanation  of  the  ap- 
pearances met  with  in  spinal  congestion.  The  gray  matter  will  be  found 
to  be  quite  dark,  and  the  vessels  are  usually  enlarged.  The  wrhite  matter 
is  often  of  a  pinkish  hue,  and  there  may  be  areas  of  hyperaemia  which  are 
localized  ;  or  the  suffusion  may  be  general.  Microscopically  examined,  the 
cord  will  be  found  to  have  undergone  very  slight  changes,  and  they  may 
consist  only  in  increased  vascularity,  enlargement  of  capillaries,  and  per- 
haps some  exudation  beneath  the  vascular  sheaths.  The  vessels  of  the  me- 
ninges  are  engorged,  and  there  are  to  be  observed  small  ecchymosed  spots, 
or  occasionally  an  effusion  of  serum.  The  symptoms  of  the  disease  result 
from  pressure  upon,  and  irritation  of,  the  nervous  elements;  and  the  vio- 
lence will  depend  upon  the  site  of  the  most  decided  hyperaemia.  The 
gray  substance,  when  subject  to  pressure  from  distended  vessels,  gives  rise 
to  the  pain  in  the  back,  and  cutaneous  hyperaesthesia,  as  well  as  the  spas- 
modic movements  which  symptomatize  the  aggravated  forms.  Spinal 
hyperaemia  is  directly  induced  by  blood  defects  and  disease  of  other 
organs,  and  it  is  favored  by  the  anatomical  structure  of  the  parts  con- 
cerned. The  tortuous  course  of  the  veins,  and  the  absence  of  valves,  are, 
according  to  Jaccoud,  among  the  latter.  The  stasis  of  blood  in  their  inte- 
rior, which  follows  forced  respiration,  such  as  must  be  caused  by  violent 
exertion,  or  by  disease  of  the  thoracic  and  abdominal  organs  which  to 
some  degree  arrests  the  return  of  venous  blood  from  the  cord,  favors 
hyperaemia. 
15 


226  DISEASES    OF    THE    SPINAL    CORD. 

Diagnosis Spinal  meningitis,  myelitis,  and  spinal  irritation  are  the 

diseases  with  which  it  may  be  confounded. 

1st.  The  spinal  pains  of  meningitis  are  increased,  as  has  been  shown, 
hy  movement,  which  is  not  the  case  in  spinal  congestion,  and  there  is  a 
muscular  rigidity  in  the  first-mentioned  disease  which  does  not  exist  in 
this. 

2d.  Myelitis  differs  from  spinal  congestion  for  the  reason  that  complete 
unrest  hesia,  wasting,  loss  of  electric  contractility  and  sensibility,  reflex- 
excitability,  incontinence  of  urine  and  feces,  and  bedsores,  belong  to  the 
former. 

3d.  Spinal  irritation  (antemia?).  The  spinal  tenderness  is  increased 
by  pressure  in  anarnia,  and  there  is  no  cutaneous  tingling.  There  are 
troubles  of  other  organs,  and  generally  a  variable  amount  of  hysteria. 
Hammond  alludes  to  the  fact  that  urinary  troubles,  when  they  ex^t. 
antedate  the  spinal  anirmia,  while  in  spinal  congestion  they  are  secondary. 

Prognosis. — The  chances  for  recovery  are  very  good,  provided  active 
measures  are  at  once  taken  to  reduce  the  fulness  of  the  spinal  vessels.  If 
the  condition  becomes  a  chronic  one,  even  then  much  may  be  done  to  im- 
prove the  abnormal  state  of  the  circulation.  In  many  cases,  however,  it 
precedes  myelitis,  particularly  when  it  takes  the  slow  course  which  I  have 
described  as  subacute  spinal  hyperrcmia,  or  it  may  lead  to  atrophy ;  but 
this  tissue-change  is  more  directly  induced  by  spinal  anaemia. 

Treatment The  local  application  of  cups,  counter-irritants,  and 

••old  may  all  be  practised;  and,  in  addition,  we  may  use  either  hydrobromie 
acid  (FF.  (>,  7),  the  bromides,  or  ergot,  in  full  doses;  or  belladonna  (F.  70), 
till  some  of  the  toxic  effects  are  produced.  It  is  never  well  to  prescribe 
alcohol,  strychnine,  or  iron  in  these  cases,  or  any  other  agents  which  in- 
crease central  irritability,  and  I  have  witnessed  disastrous  effects  from 
their  use.  The  Turkish  bath  is,  I  think,  one  of  the  best  adjuvants  to 
these  forms  of  treatment.  As  a  local  application  to  the  spine,  I  have 
directed  the  patient  to  procure  a  strip  of  adhesive  plaster,  which  should 
extend  from  the  lower  cervical  vertebra  to  the  sacrum.  This  is  to  be 
warmed  and  dusted  with  red  pepper,  and  then  applied  to  the  back.  It  is 
a  very  excellent  form  of  counter-irritant,  and  may  be  worn  for  some  time. 
The  cups  may  be  wet  or  dry,  according  to  the  severity  of  the  case,  although 
I  prefer  the  former.  Should  there  l>e  any  pronounced  symptoms,  these 
are  to  be  used  two  or  three  times  a  week.  It  must  be  borne  in  mind  that 
general  treatment,  such  as  the  re-establishment  of  fluxes  which  have  been 
interrupted,  and  the  regulation  of  the  functions  of  the  excretory  organs,  is  to 
!M»  undertaken  as  early  as  possible ;  for,  like  cerebral  hypenemia,  the  con- 
dition is  nearly  always  one  that  is  secondary.  As  an  immediate  remedy, 
<»ne  of  Chapman's  bags  may  be  filled  with  ice-water  and  applied  to  the 
back  for  ten  or  fifteen  minutes  at  a  time,  or  the  ether  spray  will  answer 
the  same  purpose. 


SPINAL    IRRITATION.  227 

SPINAL  IRRITATION. 

(SPIXAL    ANEMIA?) 

Synonyms — Isch&nie  de  la  moelle.     Anaemic  de  la  moelle. 

The  brothers  Griffin1  were  the  first  to  describe  this  interesting  affection, 
and  since  the  appearance  of  their  first  paper  in  the  London  Medical  and 
Physical  Journal  in  1829,  very  little  has  been  added  to  our  knowledge  of 
this  condition,  which  was  fully  considered  so  many  years  ago.  The  pa- 
thology of  the  affection  was  by  the  Griffins  supposed  to  consist  primarily 
in  an  irritation  of  the  sympathetic  ganglia,  and  they  divided  their  cases 
into  three  varieties,  viz.,  those  in  which  the  cervical,  dorsal,  or  lumbar 
portions  of  the  sympathetic  nerves  were  involved.  In  later  years  other 
observers,  among  them  Hammond,  consider  the  affection  due  to  an  anaemic 
condition  of  the  cord,  and  the  last-mentioned  author  goes  so  far  as  to  at- 
tempt to  localize  anaemia  of  the  different  columns,  and  groups  nearly  all 
forms  of  reflex  paralysis,  etc.  under  this  head.  I  am  disinclined  to  agree 
with  him,  not  only  because  I  believe  that  spinal  irritation  depends  some- 
times upon  hyperamiia,  but  I  think  that  this  condition  is  due  more  to  a 
loss  or  abnormality  of  cell-functions.  I  am  therefore  disposed  to  adopt  the 
views  of  the  Griffins,  and  consider -"spinal  irritation"  to  be  a  condition  due 
to  a  primary  perversion  of  the  functions  of  the  sympathetic  system,  or  to 
a  secondary  ischaemic  state,  and  that  in  some  parts  of  the  cord  both  abnor- 
malities of  circulation  exist.2 

Symptoms — The  indications  of  spinal  irritation  are  quite  varied,, 
but  there  are  several  which  are  distinctly  pathognomonic.  One  of  these  is 
spinal  tenderness.  If  the  observer  makes  firm  pressure  with  his  thumb  at 
different  points  over  the  intervertebral  spaces,  he  may  cause  the  patient 
to  wince  where  a  painful  point  receives  the  pressure.  These  tender  spots 
may  be  either  in  the  cervical,  dorsal,  or  lumbar  regions,  but  more  often 
the  cervical  or  dorsal.  Sometimes  the  skin  is  so  hyperaesthetic  at  these 
places  that  the  pressure  of  the  clothing  is  sufficient  to  cause  the  wearer 
great  discomfort;  and  such  patients,  be  they  women,  are  fidgety  and  irri- 
table. Pressure  made  at  certain  points  may  be  followed  by  pain,  not  only 
in  the  region  pressed  upon,  but  at  distant  parts;  for  instance,  in  one  of 

1  Observations  on  Functional  Affections  of  the  Spinal  Cord  and  Ganglionic 
System  of  Nerves,  etc.,  by  Wni.  and  Daniel  Griffin.     London,  1834. 

2  Dr.  V.  P.  Gibney  advanced  the  view  before  the  American  Neurological  So- 
ciety (session  of  1877)  that  spinal  irritation  was,  in  the  majority  of  cases,  a  me- 
iningeal  affection,  and  was  usually  the  result  of  injury  of  some  kind.     In  support 
of  this  theory  he  brought  forward  a  number  of  cases,  all  of  them  of  great  interest. 
I  am  strongly  inclined  to  accept  Dr.  Gibney's  explanation,  but  not  in  its  entirety. 
Spinal  irritation  is  very  probably  due  not  only  to  affections  of  the  cord  alone,  but 
to  the  mcninges  as  well,  as  the  symptoms  of  spinal  tenderness  suggest.     That  a 
great  many  cases  arise  from  disordered  functions  of  other  organs,  there  can  be  no 
doubt,  and  the  history  of  injury  is  very  often  absent. 


228  DISEASES    OF    THE    SPINAL    CORD. 

Griffin's  cases  pressure  made  over  the  dorsal  vertebra  was  followed  by  pain 
in  the  sternum.     Pain  also  of  a  darting  or  lancinating  character  followi 
such  pressure,  and  sometimes  when  the  lumbar  region  is  its  seat  there 
may  be  twinges  which  travel  down  the  crural  and  sciatic  nerves.     So, 
too,  may  there  be  radiation  of  pain  about  the  chest  when  the  dorsal  por- 
tion of  the  cord  is  subjected  to  this  procedure.     Pressure  over  the  cervi- 
cal intervertebral  spaces  produces  vertigo,  headache,  and  nausea.     With 
irritation  of  the  cervical  region,  vertigo  is  quite  pronounced.     Memory 
is  affected,  and  hysterical  manifestations  are  quite  common;  while  in- 
somnia and  headache,  disordered  vision  and  facial  neuralgia.,  vomiting. 
and  respiratory  troubles  are  all  prominent  symptoms.     The  headache  is 
connected  with  soreness  of  the  scalp,  and  is  of  a  neuralgic  character,  and 
the  fifth  nerve  is  so  extensively  affected  that  toothache,  faceache,  and  deep 
orbital  pains  when  they  occur,  are.  almost  intolerable.     As  an  evidence  of 
disordered  function  of  the  fifth  nerve,  there  may  be  trophic  changes  in  the 
cornea,  such  as  ulceration,  and  there  is  in  some  cases  keratitis.     Cervico- 
brachial  neuralgia  may  exist  in  addition  to  the  facial  neuralgia,  and  may 
lie  either  one-sided  or  bilateral,  and  pressure  made  upon  the  cervical  ver- 
tebrae may  greatly  aggravate  the  neuralgia.     Diplopia,  amaurosis,  and 
other  visual  troubles  are  annoying  in  the  extreme,  and  the  intense  hyper- 
ivsthetic  state  of  the  organs  of  special  sense  may  give  rise  to  hallucinations 
of  sight  or  hearing.      There  is  not  rarely  photophobia  of  a  distressing 
character,  so  that  the  individual  is  obliged  to  stay  in  a  darkened  room. 
Deafness  is  an  occasional  symptom,  and  ringing  in  the  ears  is  an  indica- 
tion of  cerebral  ana-mia  coexistent  with  the  spinal  troubles.     The  gastric 
mucous  membrane  may  be  in  an  extremely  irritable  condition,  so  that 
the  food  is  speedily  ejected,  and  with  the  vomiting  there  are  nausea  and 
vertigo.     The  spinal  origin  of  this  symptom  may  be  satisfactorily  proved 
by  applying  a  blister  to  the  painful  spot.     Various  respiratory  and  cardiac 
irregularities   are   quite    constant   accompaniments   of    spinal    irritation. 
Among  these  are  attacks  of  dyspepsia,  angina,  palpitation,  coughing,  or  a 
sense  of   pressure  and   discomfort   in   breathing,   asthma,  etc.     Urinary 
troubles  may  exist  when  the  morbid  spinal  condition  is  situated  lower 
down,  and  often  ovarian  neuralgia.     Convulsive  movements  of  the  legs 
and  obstinate  constipation  swell  the  list  of  symptoms.     A  form  of  paraple- 
gia, usually  of  an  hysterical  nature,  but  sometimes  so  constant  as  to  seem 
to  be  dependent  upon  some  organic  lesion,  occasionally  symptomatizes  the 
disease.     There   is  even   lowered   temperature,  though  the  patient  may 
complain  of  subjective  sensations  of  warmth;  but  the  paraplegia  is  never 
attended  by  any  evidences  of  the  real  condition  which  follows  myelitis. 
The  action  of  the  bladder  and  rectum  is  normal,  and  the  electro-muscular 
contractility  and  reflex  excitability  are,  if  anything,  increased,  and  the 
anaesthesia  or  hyperaesthesia,  if  it  exists,  is  quite  unimportant. 

The  following  history  was  given  to  me  in  the  patient's  words,  and  is  so 
graphic  that  I  consider  it  worthy  of  reproduction : 

1st  year,  18K7.  There  was  some   cerebral  anaemia.     Inability  to  think 
consecutively,   or  to  do  anything  that  required  looking  after;  constant 


SPINAL    IRRITATION.  229 

nausea  and  dizziness ;  a  burning  in  head  and  spine,  and  an  occasional 
deep  seated  and  momentary  pain  in  the  head;  an  excessive  demand  for 
pure  air ;  extreme  hyperaesthesia  of  skin ;  sleeplessness ;  worried  feeling  in 
the  ovaries. 

~2d  year,  18G8.  Head  symptoms  slightly  improved;  body  grew  weak  and 
tremulous;  felt  as  if  starving  to  death,  though  with  good  appetite  for 
nourishing  food.  Nausea  not  constant,  but  occurring  every  night  between 
nine  and  ten,  and  lasting  about  an  hour. 

3d  year,  1869.  Mind  grew  painfully  active,  it  was  impossible  to  stop 
thinking  asleep  or  awake  ;  gradual  loss  of  use  of  arms  and  legs,  with  dis- 
tressing jerkings  of  latter  ;  hysterical;  light  and  sound  almost  intolerable. 

it//  year,  1870.  Commenced  walking  after  lying  in  bed  seven  months. 
Dizziness,  sleeplessness,  tremor ;  burning  in  head  and  spine  continued. 

Qth  year,  1871.  Same  as  fourth  year,  with  some  alleviation. 

Gt/t  year,  1872.  Material  changes  were  more  sleep,  arrested  condition  of 
brain,  and  tremor  not  constant. 

~t/t  year,  1873.  Dizziness,  which  had  been  constant  from  the  beginning, 
ceased.  Ability  to  converse,  and  listen  to  any  amount  of  reading,  attend 
lectures,  etc.  Pain  or  distressed  feeling  in  head  most  of  time.  More  de- 
pression of  spirits  than  ever;  sleep  full  of  nightmare.  Neuralgic  pain; 
appetite  indhferent;  bowels  torpid;  menses  irregular  and  over-abundant, 
extremely  painful,  and  prostrating. 

The  patient  was  29  years  old,  and  married.  She  is  in  appearance 
anaemic,  evidently  of  a  strumous  diathesis,  and  somewhat  hysterical.  Her 
pupils  are  dilated,  and  there  is  decided  muscular  asthenia.  She  cannot  read, 
and,  when  she  attempts  to  do  so,  there  is  a  peculiar  dizziness,  or,  as  she 
very  pertinently  calls  it,  a  "nausea  of  the  brain."  If  reading  is  persisted 
in,  the  dizziness  is  excessive,  and  there  is  ultimately  vomiting.  Her  head- 
ache is  vertical,  and  some  uneasiness  is  produced  by  pressure  made  over 
cervical  vertebrae.  Her  urine  is  copious  and  abundant,  and  contains  phos- 
phates. Constipation  is  persistent,  and  obstinate.  At  my  request  Dr. 
Lorjng  examined  her  eyes  with  the  ophthalmoscope,  and  found  atrophy  of 
the  left  optic  disk. 

Jan.  30,  1874.  Strychnia,  iron,  and  phosphoric  acid  were  given,  and 
absolute  rest  required  and  enjoined;  and  one  month  later  she  returned, 
feeling  very  much  improved.  It  is  possible  for  her  to  read  two  hours  at 
a  time  without  being  fatigued,  and  her  spirits  are  very  much  improved; 
her  depression  has  somewhat  disappeared,  and  she  sleeps  much  better.  A 
curious  feature  of  this  woman's  disease  was  excessive  somnolency  during 
the  day,  and  it  was  often  necessary  to  use  violent  measures  to  arouse  her 
from  her  very  profound  sleep.  During  the  evening  she  became  very  ani- 
mated and  bright,  talking  brilliantly  upon  all  subjects,  and  it  was  not 
until  midnight  before  she  again  felt  a  disposition  to  sleep.  In  her  case 
evidently  the  menorrhagia  was  the  cause  of  the  anaemia. 

Causes. — The  victims  of  spinal  irritation  are  nearly  always  women, 
very  rarely  men.  It  may  safely  be  said  that  nine-tenths  of  all  the  cases 
are  females.  It  rarely  occurs  before  puberty,  but  after  that  time  may 
make  its  appearance,  and  then  is  generally  dependent  upon,  or  asso- 
ciated with,  irregular  or  profuse  menstruation.  It  not  rarely  begins  at 
the  menopause,  but  is  more  often  of  earlier  origin.  Hereditary  predis- 
position seems  to  have  much  to  do  with  its  development.  Various  mental 


230  DISEASES    OF    THE    SPINAL    CORD. 

causes  piny  an  important  part  in  its  production ;  care,  worry,  and  over-- 
work being  among  these.  Various  debilitating  diseases,  childbirth,  and 
bud  habits,  may  be  enumerated  as  additional  causes. 

Morbid  Anatomy  and  Pathology — Spinal  irritation  being  a 
functional  disease,  it  is  impossible  to  find  any  post-mortem  indications, 
unless  they,  perhaps,  are  foci  of  low  inflammatory  action,  such  as  thicken- 
ing of  the  neuroglia,  or  simple  atrophy. 

As  to  its  pathology,  I  have  already  expressed  my  views  in  regard  to 
the  probability  of  both  hyperaemic  and  aiuemic  conditions  as  pathological 
factors.  It  is  impossible,  I  am  convinced,  to  locate  the  point  of  irritation 
in  either  of  the  columns,  and  any  attempt  to  do  so  is  an  unwarranted  and 
impossible  refinement  of  diagnosis.  We  may  approximate  its  seat  by  tin- 
region  of  tenderness,  and  the  predominance  of  special  groups  of  svmp- 
tonis;  and  this  is  all  that  I  believe  to  be  possible.  Spinal  irritation  mav 
undoubtedly  result  from — 1,  reflected  irritation;  2,  impoverished  blnod- 
supply;  3,  local  changes  dependent  upon  disease  of  adjacent  tissues. 

The  labors  of  Brown-Sequard,  Bernard,  and  lately  Lauder  Brunton. 
have  proved  most  satisfactorily  the  intimate  relation  between  the  sympa- 
thetic and  cerebro-spinal  systems;  and  the  observations  of  the  former  are 
especially  valuable  because  of  their  pathological  bearing.  Not  only  may 
distant  organs  send  irritating  impressions  to  the  cord,  to  be  followed  by 
vaso-motor  stimulation,  contraction,  and  subsequent  relaxation  of  the 
vessels,  but  the  intru-spinal  circulation  of  impure  blood  may  produce  local 
irritation,  imperfect  nutrition  of  the  nerve-cells,  shrinkage,  of  the  nervous 
tissue,  and  oedema  of  the  peri  vascular  spaces.  The  chain  of  inhibitory 
ganglia,  described  in  such  a  beautiful  manner  by  Brunton,  places  in  close 
relation  the  different  parts  of  the  cerebro-spinal  axis,  so  that  then-  is 
nearly  always  a  disturbance  of  several  organs  when  the  harmony  is  af- 
fected. 

The  vascular  cramp  of  Xothnagel  will  account  for  various  iscluvmic 
conditions  in  certain  parts,  while  circulation  in  neighboring  districts  may 
be  perfectly  normal.  Bidder1  has  also  shown  that  complete  alteration  of 
vascular  calibre  is  impossible,  so  that  at  best  there  is  contraction  but  at 
a  certain  point,  while  the  other  part  of  the  vessel  may  be  dilated. 

Bidder's  experiments  also  demonstrated  that  excitement  or  exaggera- 
tion of  function  may  exist  with  depressed  function  at  the  same  time,  in  a 
compound  organ. 

It  is  therefore  reasonable  enough  to  consider  that  spinal  irritation  is  not. 
altogether  dependent  upon  spinal  ana-mia. 

The  production  of  special  symptoms  is  explained  by  the  involvement 
of  sympathetic,  cranial,  or  spinal  nerve-roots.  The  headache  may  result 
from  cerebral  ana-mia,  as  may  also  the  mental  and  hysterical  symptoms  ; 
while  the  visceral  disturbances  arise  from  sympathetic  derangement  of  the 


1  Die  Rt-flexu  sines  der  sensiblen  Ncrven  du  Herzen  auf  die  rnotorische  du 
Blutgefasse. 


SPINAL    IRRITATION.  231 

abdominal  organs.  The  pain  resulting  from  pressure  is  due  to  impressions 
conducted  to  the  over-sensitive  centre  by  the  cutaneous  nerves.  It  is 
almost  unnecessary  to  allude  to  the  production  of  spasms,  reflected  pain, 
and  the  numerous  dysaesthesia. 

Diagnosis — Spinal  congestion,  spinal  meningitis,  and  incipient  in- 
flammation of  the  cord,  may  suggest  themselves  to  the  observer.  As  to 
the  first,  differential  diagnosis  is  often  impossible,  unless  there  be  actual 
paresis.  The  absence  of  great  spinal  tenderness  is  also  an  element  in 
diagnosis.  Spinal  meningitis  is  connected  with  tenderness,  but  it  is  not 
aggravated  so  much  by  pressure  as  by  muscular  movements.  There  are 
also  present  muscular  spasms  of  a  painful  character. 

Myelitis  in  the  beginning  is  attended  by  waist  constriction,  which  is  too 
marked  to  be  mistaken ;  and  besides  paralysis  of  motion  and  sensation, 
there  is  atrophy,  as  well  as  progressive  symptoms.  The  presence  of  gastric 
symptoms,  which  are  so  marked  in  nearly  all  cases  of  spinal  irritation,  of 
headache,  and  great  languor,  a  generally  depraved  physical  state,  and  the 
existence  of  uterine  trouble,  should  all  be  taken  into  account. 

Griffin  alluded  to  several  other  disorders  likely  to  produce  some  of  the 
symptoms  of  spinal  irritation.  These  are  rheumatism,  which  is  sometimes 
causative  of  spinal  soreness,  and  various  acute  diseases,  which,  however, 
present  so  many  symptoms  of  a  distinct  character  as  to  do  away  with  any 
chance  for  mistakes  in  diagnosis.  The  pain  of  rheumatism  is  generally  so 
severe  and  absorbing  that  the  patient's  mind  is  constantly  directed  to  it, 
while  affections  of  the  joint  usually  coexist. 

Prognosis  and  Treatment. — If  the  patient  be  promptly  taken  in 
hand  it  is  often  possible  to  cure  the  disease,  but  I  am  inclined  to  consider 
well-established  spinal  irritation  the  most  discouraging  and  intractable 
functional  neurosis  that  is  to  be  met  with.  Commonly  connected  with 
ovarian  or  uterine  derangement,  it  defies  the  best-directed  efforts  of  the 
physician ;  and,  if  the  factor  cannot  be  removed,  the  patient  becomes  a 
confirmed  invalid.  It  is,  therefore,  proper  in  all  cases  to  search  for  the 
cause,  and  in  three-quarters  of  the  female  cases  it  will  be  found  in  the  pel- 
vis. If  there  be  general  anosmia,  or  some  other  depraved  condition  of  the 
system,  we  are  to  "  build  up"  our  patient  with  cod-liver  oil  and  tonics 
(FF.  57,  43,  7,  8,  9),  and  a  very  excellent  one  is  the  following: — 

R.   Ferri  et  ammon.  citratis,  Jjiij  ; 

Tr.  gentianas,  §iv. — M. 
Sig. — A  teaspoonful  in  water  after  eating. 

Phosphorus,  either  in  the  form  of  Thompson's  solution  (FF.  24,  25,  26) 
or  the  phosphuretted  oil,  quinine,  pyrophosphate  of  iron,  Horsford's  acid 
phosphates  (F.  72),  the  syrup  of  the  combined  phosphates  (F.  73),  are  all 
in  order.  Nutritious  food  and  extract  of  malt  are  to  be  given,  and  a  liberal 
use  of  stimulants  is  strongly  recommended.  Strychnine  sometimes  does 
good,  and  at  others  does  a  great  deal  of  harm  ;  and  in  cases  where  there  is 
very  severe  pain,  I  prefer  other  remedies. 

Opium  in  small  doses  is  often  of  great  value,  and  its  effects  are  imme- 


232  DISEASES    OF    THE    SPINAL    CORD 

dinte  and  excellent.  External  counter-irritation,  either  -by  the  actual 
cautery  applied  on  the  painful  points,  a  blister,  or  some  irritating  oint- 
ment, is  advised,  and  if  vomiting  be  present,  a  blister  on  the  «-|iijr:istrium, 
subsequently  dusted  with  morphia,  allays  the  irritability  of  the  stomach.  I 
have  used  with  success,  and  would  recommend,  galvanism  (the  descending 
current),  the  positive  pole  being  placed  upon  the  nucha,  and  the  negative 
in  the  groin.  Five-minute  seances  every  day,  or  every  other  day,  are 
sufficient. 

Galvanization  of  the  cervical  sympathetic  is  an  important  form  of  auxil- 
iary treatment.  Heat  and  cold  alternately  applied  to  the  spine  are  followed 
by  excellent  results ;  or  Chapman's  ice-bags,  filled  with  hot  water,  and 
placed  in  contact  with  the  spine  for  fifteen  or  twenty  minutes  daily,  are 
beneficial.  * 

Open-air  exercise,  Turkish  baths,  massage,  all  help  the  patient ;  and 
Mitchell's  rest-treatment,  already  described,  is  one  of  our  best  modes  of 
treatment  in  confirmed  cases. 


ACUTE    MYELITIS.  233 


CHAPTEE   IX. 

DISEASES  OF  THE  SPINAL  CORD  (CONTINUED). 

INFLAMMATION  OF  THE  SPINAL  CORD— MYELITIS. 

Synonyms Myelitis.     Mye'lite  aigue,  chronique. 

Definition — Inflammation  of  the  spinal  cord,  usually  attended  by 
paralysis  of  motion  and  sensation  below  the  seat  of  the  spinal  lesion,  by 
involuntary  stools  and  incontinence  of  urine,  and  by  absence  of  reflex  ex- 
citability and  electric  contractility  in  the  paralyzed  parts,  and  a  tendency 
to  extension  upwards,  results  in  death  in  a  very  short  time  from  paralysis 
of  the  intercostal  muscles,  especially  should  the  pathological  condition  be 
an  acute  one. 

ACUTE    MYELITIS. 

Symptoms The    disease   begins   rather  suddenly,  generally  with 

pain  in  the  back,  which  is  aggravated  by  pressure,  and  an  uneasy  sense  of 
tightness  about  the  waist.  These  unpleasant  sensations  may  be  preceded 
by  formication  and  tingling  of  the  feet,  some  loss  of  power,  and  the  devel- 
opment of  more  or  less  fever,  during  which  the  temperature  may  be  very 
much  elevated.  These  symptoms  are  followed  in  several  hours,  or  after  a 
day  or  two,  by  loss  of  power  in  the  lower  limbs  and  by  an  aggravation 
of  the  spinal  pain.  The  patient  will  find  it  impossible  to  pass  his  urine, 
and  if  he  is  not  relieved  by  a  catheter  will  suffer  great  distress  ;  or  there 
may  be  final  relaxation  of  the  sphincter,  and  it  may  flow  from  him  without 
his  knowledge.  These  symptoms  are  sometimes  presented  before  a  phy- 
sician is  called  in,  and  at  his  visit  there  may  be  complete  paralysis  of  the 
lower  extremities.  The  surface  of  the  limbs  is  cold  and  utterly  devoid  of 
sensation,  and  the  soles  may  be  tickled  or  the  muscles  pinched  without 
any  attempt  being  made  upon  the  part  of  the  patient  to  withdraw  his  feet. 
This  reflex  excitability,  however,  is  not  always  lost  in  the  beginning,  but 
may  be  present  when  the  onset  of  the  disease  is  gradual,  and  the  patient 
is  entirely  unconscious  of  the  occurrence  of  these  movements.  If  a  heated 
substance  be  applied  to  the  back,  it  will  be  found  that  its  presence  will  not 
be  appreciated  below  the  point  of  spinal  inflammation,  but  when  it  is 
passed  over  the  diseased  tract  the  pain  is  greatly  increased.  Above  this 
level,  normal  sensibility  exists,  and  the  degree  of  heat  is  readily  perceived. 
The  attention  of  the  physician  is  attracted  by  the  ammoniacal  odor  of  the 
urine,  which,  as  has  been  stated,  may  flow  from  the  patient  without  his 
knowledge,  and  the  contents  of  his  rectum  may  pass  away  in  the  same 


234  DISEASES    OF    THE    SPINAL    CORD. 

manner.  Ilypencsthcsia  is  sin  exceptional  feature,  but  it  may  form  one  of 
the  initial  symptoms  in  conjunction  with  trembling  of  the  limbs.  After 
the  paralysis  takes  place,  the  temperature  is  lowered  several  decrees.  :md 
circulation  is  verv  defective.  At  the  end  of  a  week  there  may  be  indica- 
tions of  the  upward  extension  of  the  spinal  inflammation  if  it  be  progres- 
sive, and  it  is  sometimes  recognized  by  the  tendency  to  priapism  and  the 
distress  in  breathing,  and  with  these  there  may  be  hiccough  and  hurried  re- 
spirations, their  number  perhaps  reaching  48  in  the  minute.  Bedsores  form 
over  the  sacrum,  and  there  is  every  appearance  of  approaching  dissolution. 
The  skin  becomes  clammy,  and  there  may  be  rigors;  while  the  pul>e  gm\v< 
small,  fluttering,  and  the  voice  very  weak,  and  ultimately  the  patient  dies. 
his  mind  remaining  clear  to  the  end.  If,  however,  the  structural  altera- 
tion progresses  upward,  it  is  very  probable  that  the  mode  of  death  will  be 
asphyxia.  As  exceptional  instances,  cases  have  been  recorded  in  which 
there  was  myelitis  of  the  upper  part  of  the  cord,  with  complete  paralysis  of 
the  upper  extremities,  while  the  lower  limbs,  the  bladder,  and  rectum  were 
not  affected,  and  other  equally  rare  forms  are  occasionally  noted.  When 
the  dorsal  (>ortion  of  the  cord  is  the  seat  of  inflammatory  action,  the  re- 
spiratory symptoms  are  immediate,  and  the  breathing  becomes  embarrassed 
at  once. 

The  prominent  symptoms  of  this  interesting  neurosis  may  be  recapitu- 
lated as — 

1.  Paraplegia  of  sudden  or  gradual  origin,  attended  by  anaesthesia 
and  analgesia,  but  usually  preceded  by  dysresthesia  of  various  kinds,  or 
actual  hypenrsthesia.  It  may  be  accompanied  in  the  beginning,  accord- 
ing to  Kadclifte,1  who  has  observed  this  symptom  in  severe  cases,  by  "un- 
controllable restlessness."  Paraplegia  is  nearly  always  the  form  of  lost 
power,  though  in  rare  cases  there  is  hemiplegia.  There  may  be,  in  excep- 
tional cases,  variations  in  sensibility,  the  symptoms  of  aiuesthesia  being 
absent  when  the  anterior  columns  are  alone  partially  affected.  Again,  in 
other  cases  one  leg  may  be  paralyzed  and  the  other  anaesthetic.  Tin- 
onset  of  the  paraplegia  may  be  very  sudden,  and  the  disease  prove  rapidly 
fatal.  Jsiccoud"  has  seen  one  case  in  which  the  paraplegia  developed  in 
thirty-six  hours  from  the  commencement  of  the  disease.  Eighteen  hours 
afterwards,  the  autopsy  revealed  a  purulent  meningo-myelitis  of  the.  entire 
lumbar  and  part  of  the  dorsal  segments  of  the  cord.  The  extent  of  the 
paraplegia  is  of  course  governed  by  the  seat  and  course  of  the  myelitis.  If 
the  lumbar  portion  of  the  cord  be  destroyed,  the  lower  extremities,  and  the 
muscles  of  the  abdomen  and  sphincters  will  be  paralyzed;  if  the  myelitis 
extends  so  that  the  dorsal  portion  and  the  cilio-spinal  centre  are  involved, 
the  arms  are  paralyzed,  and  pupillary  changes  with  irregularity  of  cardiac 
functions  are  produced.  When  the  lesion  is  still  higher,  and  the  cervical 
jxu-tion  of  the  cord  is  involved,  there  may  be,  in  addition  to  all  these 
forms  of  paralysis,  various  difficulties  in  swallowing,  speech,  and  respira- 
tion, and  the  patient  dies  from  asphyxia. 


Op.  cit.,  p.  315.  *  Path.  Interne,  vol.  i.  p.  314. 


ACUTE    MYELITIS.  235 

2.  Reflex  excitability  is  generally  abolished  entirely,  or  impaired  to  a 
great  extent.     Occasional  exaggeration  is  seen  in  the  earliest  stages,  or 
when  the  myelitis  involves  limited  regions,  especially  the  lumbar  segment. 
Jaccoud  says  :!  "  Durant  la  periode  d'exageration  (hyperkinesie  reflexe) 
le  segment  lombaire  soustrait  a  1'influence  du  cerveau  manifest-ait  son  action 
propre  avec  la  puissance  accrue  qu'elle  tirait  de  son  isolement ;  durant  la 
periode  d'abolition  (akinesie  reflexe)  cette  action  propre  ou  spinale  est 
aneantie  parceque  les  elements  qui  en  sont  doue'-;  sont  detruits." 

3.  Electric  contractility  and  sensibility  are  abolished  or  greatly  lowered. 
The  only  exception  to  this  rule  is  when  the  reflex  excitability  is  increased. 

4.  Muscular  atrophy  as  a  result  of  severance  of  spinal  innervation 
sometimes  follows.     This  may  take  place  in  from  four  to  six  weeks.     The 
atrophy  is  general,  and  is  of  course  attended  by  absence  of  electro-mus- 
cular contractility  and  by  coldness  of  the  surface. 

5.  Bedsores  and  other  evidences  of  defective  cutaneous  innervation  are 
present.     The  skin  becomes  swollen,  or  there  may  be  at  first  great  dryness 
and  redness,  or  oedema  at  the  points  subjected  to  pressure.     A  hard,  red 
bullous  nodule  may  form,  and  subsequently  break  down,  and  sometimes 
large  patches  of  tissue  are  rapidly  destroyed. 

6.  The  sphincters  are  paralyzed,  the  urine  is  intensely  alkaline,  the 
walls  of  the  bladder  being  paralyzed,  and  as  a  consequence  a  certain 
amount  of  urine  remains  in  that  organ  in  a  decomposed  state,  and  rapidly 
induces  an  alkaline  reaction  in  that  which  may  collect  before  it  is  dis- 
charged.    Though  Brown-Sequard  is  inclined  to  consider  that  this  con- 
dition of  affairs  is  pathognomonic  of  disease  of  the  dorsal  region,  and  I 
infer  holds  that  it  is  essentially  a  nervous  symptom,  I  am  compelled  to 
believe  that  it  is  only  an  intra-vesical  change,  and  occurs  in  this  disease  just 
as  it  may  in  various  local  troubles,  such  as  cystitis,  prostatitis,  or  other 
affections  in  which  the  expulsive  force  of  the  organ  is  affected,  perhaps 
the  walls  being  thickened  as  a  result  of  local  trouble.     Kadcliffe  alludes  to 
a  reflex  spasm  of  the  sphincter  ani  which  occasionally  occurs  in  this  dis- 
ease, but  this  symptom  is  so  exceptional  as  to  need  but  passing  comment. 
The  paralysis  of  this  muscle  is  ordinarily  so  complete  as  to  be  followed  by 
the  almost  constant  escape  of  softened  feces  and  watery  discharges. 

7.  Increase  of  temperature   and  pulse   calls  for  no  special  mention. 
Occurring  with  paralysis  of  the  lower  extremities  and  no  loss  of  conscious- 
ness they  can  symptomatize  but  two  acute  spinal  affections,  myelitis  and 
meningitis.     The  spasmodic  movements  of  the  latter  disease,  however,  are 
not  observed  in  myelitis,  so  that  it  possesses  at  least  some  diagnostic  im- 
portance.    The  temperature  varies  from  the  normal  standard  to  104°  or 
105°,  and  the  pulse  may  reach  160. 

8.  The  constricting  band  sensation,  which  is  more  marked  in  myelitis 
than  any  other  form  of  spinal  disease,  is  generally  likened  by  the  patient 
to  that  which  might  result  if  a  tight  cord  were  tied  about  the  body.     It  is 
usually  located  at  the  waist,  and  sometimes  when  it  is  not  complained  of 

1  Op.  cit.,  vol.  i.  p.  315. 


236  DISEASES    OF    THE    SPINAL    CORD. 

may  be  developed  by  a  sharp  blow  on  the  back,  or  by  the  application  of  an 
electrode  to  the  spine. 

CHRONIC    MYELITIS. 

Symptoms The  disease  sometimes  takes  a  more  slow  course.  The 

paralvlic  symptoms  are  much  less  sudden  in  their  onset,  and  occur  one  after 
another,  so  that  the  extension  of  the  inflammation  may  be  sometimes 
traced.  For  some  time,  perhaps  for  several  months,  there  may  be  di«-i>rd<-r< 
of  sensation,  such  as  tingling  spinal  pain,  and  the  "constricting  band." 
The  perception  of  pain  in  the  affected  limbs,  though  not  entirely  abolished, 
is  greatly  influenced. 

Charcot,1  Romberg,8  and  Cruveilhier3  have  called  attention  to  the 
curious  mistakes  sometimes  made  by  patients  in  locating  painful  sensations. 
Pain  following  the  pinching  of  one  leg  is  referred  to  the  other,  and  the 
painful  impression  may  take  several  seconds  to  reach  the  sensorium.  In 
one  of  Romberg*8  patients  pressure  upon  the  toe  was  referred  to  the  hip. 
Cruveilhier's  experiments  demonstrated  that  an  interval  of  from  fifteen 
to  thirty  seconds  elapsed  sometimes  before  any  sensation  was  excited,  and 
that  the  impression  had  to  be  made  several  times  before  it  was  perceived. 
Electric  contractility  is  perhaps  increased,  and  reflex  excitability  is  very 
much  exaggerated,  and  may  be  followed  by  very  violent  movements. 
Thus,  when  a  warm  bottle  is  sometimes  applied  to  the  feet,  though  the 
temperature  is  not  so  high  as  to  cause  discomfort  to  a  healthy  person  who 
touches  it,  the  patient's  legs  will  be  violently  drawn  up ;  this  always  sug- 
gests a  meningeal  complication.  Dysaesthesise  are  referred  to,  and  pains  in 
the  joints  and  bones,  especially  aggravated  by  humidity  of  the  atmosphere, 
are  s|K>ken  of  by  the  patient.  The  paralysis  of  motion  is  much  less  exten- 
sive than  it  is  in  the  acute  form  and  in  the  beginning;  and  spasms  of  the 
muscles  of  the  lower  extremity  are  very  violent.  Subsequently,  however, 
they  disapjwar  as  the  loss  of  power  becomes  more  complete,  and  at  this 
time  there  are  lowered  temperature  and  electric  irritability  instead  of  the 
primary  exaggerated  condition.  The  bladder  and  rectum  are  subsequently 
affected,  and  various  degrees  of  deranged  function  may  be  noticed. 
One  of  my  patients  is  obliged  to  pass  his  water  every  ten  or  fifteen 
minutes,  and  his  bowels  are  so  constipated  as  to  require  an  injection  every 
day.  .  The  individual  generally  loses  his  power  for  sexual  gratification  if 
the  disease  is  at  all  advanced,  though  in  the  beginning  there  may  be  a 
marked  disposition  to  erection.  Atrophy  takes  place  if  the  anterior  horns 
be  affected. 

Causes — The  common  causes  of  myelitis  are  injury,  syphilis,  acute 
diseases,  exj>osure,  and  extension  of  meningeal  disease.  Falls  and  blows 
ujMHi  the  back  are  the  origin  of  the  majority  of  cas.es,  but  I  consider 
syphilis  to  have  a  very  great  deal  to  do  with  even  these,  when  often  it  is 

1  Op.  oh. 

1  Manual  of  the  Nervous  Diseases  of  Man,  Syd.  Trans.,  vol.  i.  p.  267,  et  seq, 

*  Anatomic  Pathologique,  livre  xxxviii.  p.  9. 


CHRONIC    MYELITIS.  237 

not  suspected.  Meningeal  thickening  or  acute  meningitis  undoubtedly 
plays  an  important  part  as  a  mechanical  cause  ;  and  in  many  cases  reported, 
disease  of  the  vertebrae  has  been  found  to  produce  the  myelitis.  Venereal 
excesses,  onanism,  and  continued  dissipation  are  direct  causes  which 
should  not  be  overlooked. 

Morbid  Anatomy  and  Pathology — When  the  vertebral  canal 
is  opened,  the  investing  membranes  slit  up,  and  the  cord  exposed,  it  will 
be  found  to  be  greatly  changed  in  color  and  consistency  at  certain  parts. 
It  may  be  diffluent  and  of  a  pinkish  color.  Scattered  throughout  the 
softened  portion  collections  of  blood  may  sometimes  be  found,  and  these 
arc  more  often  in  the  greatly  altered  gray  substance,  from  which  the  dis- 
•  a-c  seems  to  have  started.  At  other  points  there  may  be  found  evidences 
of  slight  vascular  changes,  such  as  occur  in  the  red  stage  of  cerebral  soften- 
ing. There  may  be  adhesions  of  the  meninges  to  the  cortex  or  collections 
of  pus  between  them.  In  the  more  slow  form  of  degeneration  (chronic 
myelitis)  the  process  may  not  be  so  widespread,  limited  areas  being  only 
affected.  As  a  result  of  either  form  there  may  be  an  atrophic  condition  of 
the  cord,  or  an  actual  hardness  which  we  shall  presently~speak  of  in  our 
consideration  of  sclerosis.  The  microscopical  appearances  are  the  follow- 
ing :  the  vessels  are  enlarged,  varicose,  or  broken,  and  are  surrounded  by 
effused  ha?matine;  the  nerve-tubes  are  swollen,  irregular,  and  disrupted, 
and  the  axis  cylinders  substituted  by  oil-globules  or  granular  debris  ;  and 
the  nerve-cells  may  have  been  broken  down  and  become  simple  granu- 
lar masses  of  a  round  or  ovoid  shape  (Gluge's  corpuscles).  Fat  globules 
may  be  found  scattered  here  and  there  if  the  cord  of  an  advanced  case  is 
examined ;  and  the  connective  tissue  may  be  found  to  be  thickened  and 
increased  in  density.  Pus-corpuscles  may  also  be  seen.  Jaccoud1  speaks 
of  two  kinds  of  myelitis — mySKtt  en  foyer  and  my&ite  central.  In  the 
first  form  the  meninges  will  be  found  to  be  injected  and  adherent  to  the 
nervous  substance,  and  the  nodules  or  patches  may  be  several  centimetres 
in  length  or  smaller.  These  foyers  are  quite  distinctly  separated  from 
each  other  by  healthy  tissue,  and  when  one  is  removed  the  nidus  in  which 
it  has  formed  is  seen  to  be  in  quite  normal  condition.  The  anterior 
columns  and  anterior  nerve-roots  are  often  found  to  be  involved  ;  and  the 
latter  are  the  seat  of  "  petites  nodosites  exuberante"s."  When  the  dis- 
ease assumes  a  chronic  form,  these  softened  patches  may  become  encysted 
as  in  cerebral  softening.  The  central  form,  as  its  name  implies,  begins  in 
the  gray  matter,  and  generally  extends  longitudinally. 

Diagnosis It  is  necessary  to  exclude  spinal  meningitis,  locomotor 

ataxia,  spinal  tumors,  and  spinal  congestion. 

Spinal  Meningitis — What  I  have  already  said  in  a  previous  article 
renders  further  consideration  unnecessary. 

Locomotor  Ataxia — There  is  no  paralysis  of  motion  in  this  disease, 
but  rather  an  increased  muscular  activity,  which  is  expressed  by  the  vio- 
lent manner  in  which  the  patient  throws  out  his  foot ;  while  in  chronic 

1  Path.  Interne,  ed.  2me,  vol.  i.  p   310. 


238  DISEASES  OF  THE  SPINAL  CORD. 

myelitis  he  drags  one  foot  after  another.  The  neuralgic  pains  in  the  ex- 
tremities are  absent  in  myelitis;  while  in  locomotor  ataxia  they  are  marked 
symptoms.  In  myelitis  there  are  none  of  the  paralyses  of  cranial  nerves 
so  commonly  found  with  sclerosis  of  the  posterior  columns. 

Spinal  Tumors The  presence  of  a  spinal  tumor  may  sometimes  pro- 
duce pressure  upon  the  cord,  and  give  rise  to  some  of  the  symptoms.  The 
slow  development  of  the  growth  is,  however,  attended  by  corresponding 
slowly  appearing  symptoms,  and  the  paralysis  is  not  complete.  The  chance 
for  doubt  as  to  the  condition  arises  when  secondary  myelitis  results  from 
such  a  tumor. 

Spinal  Congestion These  serious  symptoms  of  myelitis  are  never  pro- 
duced by  anything  but  a  degenerative  process,  and  there  are  rarely  bed- 
sores, alkaline  urine,  or  the  profound  disturbances  of  sensation  or  motion 
which  characterize  myelitis. 

Prognosis In  every  case  much  depends  upon  the  nature  of  the 

cause,  and  the  extent  of  the  cord  involved.  If  there  be  a  traumatism,  ot 
course  this  gives  the  disease  a  serious  character,  and  death  may  occur  in 
a  few  days.  If  the  myelitis  result  from  pressure  from  diseased  and  dis- 
placed vertebnv,  the  result,  though  more  distant,  is  equally  bad.  Very 
few  cases  recover  entirely  from  chronic  myelitis,  and  in  those  that  do,  the 
lesion  must  either  be  due  to  syphilis,  or  be  very  limited. 

Treatment — Counter-irritation,  cold,  and  ergot  are  useful  in  the 
early  stages  of  the  acute  disease.  The  former  may  be  produced  by  the 
actual  cautery,  but  care  should  be  taken  not  to  burn  extensively,  as  the 
tissues  are  too  ready  to  slough.  Ice-bags  may  be  used,  and  the  patient 
should  be  laid  on  a  water-bed,  and  kept  as  clean  as  possible  ;  the  thighs 
and  nates  being  washed  occasionally  with  salt  and  water,  or  with  hot  and 
cold  water  alternately.  The  iodide  of  potassium,  with  belladonna,  should 
be  given  internally  (F.  74).  Should  the  case  be  one  of  slow  development, 
I  prefer  the  use  of  ergot  in  half-drachm  doses  thrice  daily;  or  we  may 
use  the  bromides  (F.  44). 

The  sesquichloride  of  iron  (F.  7">)  seems  to  have  enjoyed  deserved 
popularity  in  England,  and  it  is  preferred  by  Radcliffe  to  the  iodide  of 
potassium.  In  one  case  I  obtained  very  excellent  results  with  the  tincture 
of  the  chloride  of  iron.  Phosphorus  and  cod-liver  oil,  those  valuable 
builders  of  healthy  nervous  tissue,  may  be  employed  here  with  every  hope 
that  they  will  do  good.  In  chronic  myelitis  they  are  especially  service- 
able, and,  later  on,  small  and  frequent  doses  of  strychnine  are,  in  addition, 
useful.  There  are  forms  of  auxiliary  treatment  which  not  only  increase 
the  comfort  of  the  patient,  but  go  far  towards  ameliorating  his  disease. 
One  of  these  is  the  assumption,  if  possible,  of  a  position  which  shall  favor 
the  determination  of  the  blood /row  the  spine.  Brown-Sdquard  has  re- 
commended that  the  patient  should  lie  upon  his  side  or  belly,  with  his 
legs  somewhat  lower  than  the  rest  of  the  body.  I  have  found  that  wash- 
ing out  the  bladder  with  a  dilute  solution  of  carbolic  or  nitric  acid,  or 
chlorate  of  potash,  prevents  the  disposition  to  cystitis  which  there  very 


ANTERO-SPINAL    PARALYSIS    OF    INFANCY.  239 

often  is  in  myelitis.  Warmth  of  the  limbs,  established  by  wrapping  them 
in  cotton  batting,  with  a  covering  of  oil-silk,  or  the  new  India-rubber 
tissue-paper,  prevents  contractions,  and  stimulates  the  cutaneous  circula- 
tion ;  while  application  of  the  faradic  current,  and  the  employment  of  mas- 
sage, help  the  patient  to  a  great  extent.  The  electric  brush  should  be 
used  faithfully  every  day,  and  it  is  better  that  the  physician  should  make 
lii>  own  electrical  application,  than  trust  it  to  a  nurse  or  attendant. 


ANTERO-SPINAL  PARALYSIS  OF  INFANCY. 

Synonyms Paralysie  essentielle  de  1'enfance  (Rilliet  and  Barthez)  ; 

Infantile  Paralysis  (Radcliffe,  Yolkman,  and  others);  Paralysie  atro- 
phique  de  1'enfance,  Organic  Infantile  Paralysis  (Hammond) ;  Infantile 
Spinal  Paralysis  (Seguin) ;  Spinale  Kinderlahmung  (Heine). 

Definition. — This  form  of  paralysis  may  be  described  as  a  condition 
usually  characterized  by  a  primary  febrile  stage,  a  secondary  paralysis 
generally  of  the  lower  extremities,  and  a  tertiary  atrophy.  The  paralysis 
is  incomplete,  as  sensibility  is  never  lost. 

Symptoms The  disease  is  marked  by  a  febrile  onset  of  greater 

or  less  severity,  attended  by  restlessness,  malaise,  and  pains  in  the  joints 
or  back,  and  there  may  be  rigors;  or  in  some  instances  the  loss  of  motor 
power  is  preceded  by  one  or  more  paroxysms  of  convulsions.  This  febrile 
state  is  by  many  mothers  mistaken  for  "teething,"  "worms,"  or  other  un- 
important childish  troubles,  and  it  is  not  till  the  development  of  paralysis 
that  any  alarm  is  created.  This  symptom  appears  within  two  or  three 
days  from  the  beginning  of  the  fever,  and  may  take  place  at  night.  The 
onlv  condition  of  disturbed  sensibility  is  one  of  hypertesthesia,  which, 
however,  is  not  a  constant  symptom. 

Sinkler1  has  collected  a  number  of  cases  in  which  he  has  noted  the 
form  of  invasion  of  the  disease.  He  found  that  the  paralysis  took  place 
suddenly,  that  is,  with  prodromata  in  but  6  of  108  cases,  while  Mrs. 
Jacobi2  noted  this  form  of  invasion  in  12  of  163  cases  that  she  had  col- 
lected. The  modes  of  onset  are  the  following : — 

1 .  The  child,  while  playing,  suddenly  drops  palsied. 

2.  The  child  may  be  paralyzed  at  night. 

3.  Fever,  but  no  convulsions ;  rapid  loss  of  power. 

4.  Convulsions,  followed   by  sudden  paralysis.      (Sinkler   reports  but 
one  case  of  this  kind,  and  but    two   in  which  convulsions  folloiced  the 
paralysis.) 

5.  The  paralysis  preceded  by  one  of  the  exanthemata,  or  by  whooping- 
cough. 

1  Clinical  Lecture,  Med.  and  Sur<j.  Reporter,  March  10,  1877. 

2  Am.  Journ.  of  Obstetrics,  May,  1874. 


240  DISEASES    OP    THE    SPINAL    CORD. 

6.  Gradual  development,  perhaps  limping  at  first,  and  afterwards  com- 
plete paralysis,  but  no  acute  symptoms. 

In  this  exceedingly  valuable  lecture,  Sinkler  throws  much  light  upon 
the  symptomatology  of  the  disease,  and  gives  the  details  of  a  rla-sieal 
case. 

The  paralysis  may  take  the  form  of  hemiplegia,  or  it  may  affect  the 
voluntary  muscles  of  all  four  extremities,  and  some  of  those  of  the  trunk  ; 
but  the  facial  muscles,  as  a  rule,  escape.  After  a  short  time  there  is  a 
return  of  power  in  many  of  those  at  first  involved,  and  but  a  small  number 
of  muscles  (notably  the  anterior  tibial,  peroneal,  and  others  of  the  leg  and 
thigh)  remain  powerless. 

The  temperature  of  the  paralyzed  muscles  is  much  lowered,  and  Ham- 
mond lias  seen  a  difference  of  from  eight  to  ten  degrees  between  the 
affected  and  normal  sides.  The  bladder  and  bowels  escape  the  paralysis, 
and  their  functions  are  consequently  unimpaired. 

Muscular  contractility  is  lost  with  the  commencement  of  the  paralysis, 
and  the  faradic  current  will  rarely  produce  contractions.  Such,  however, 
is  not  the  case  with  the  galvanic,  except  in  extreme  instances,  or  when 
the  case  is  one  of  long  standing.  80  far  there  are  rarely  any  evidences  of 
atrophy  or  contractures  of  the  paralyzed  muscles,  but  it  will  be  found  now 
that  certain  muscles  at  first  affected  begin  to  regain  their  lost  functions, 
while  others  become  atrophied  and  utterly  useless.  Even  the  galvanic 
current  fails  to  stimulate  them  ;  and  at  this  period,  which  may  vary  from 
four  to  five  weeks  to  six  months  from  the  beginning  of  the  disease,  there 
may  be  deformities  and  muscular  contractures,  which  may  result  cither 
from  the  weight  of  the  body  upon  the  affected  limb,  or  from  the  antagonism 
of  non-paralyzed  muscles;  but  Volekmann1  considers  that  this  incapacity  of 
the  limb  to  support  the  superimposed  load  is  of  much  greater  importance 
as  a  cause  of  deformity  than  the  mere  antagonism  of  the  unaffected  muscles. 

Those  deformities  may  take  place  as  lateral  curvature  of  the  spine,  tali- 
pes, and  other  distortions  which  appear  as  various  muscles  are  paralyzed, 
or,  if  there  be  shortening  of  the  limb  (which  is  by  no  means  uncommon), 
as  a  consequence  of  reduction  in  the  length  and  size  of  bones  which  have 
become  atrophied.  The  deformities  that  may  result  from  the  disease  under 
consideration  are  of  \\primary,  and  of  a  secondary  or  compensatory  nature. 
The  primary  forms  are  those  which  are  seen  as  talipes  of  both  kinds,  and 
result  from  loss  of  sustaining  power  of  the  muscles.  The  compensatory 
consist  in  spinal  curvatures,  such  as  lordosis  or  scoliosis.2  The  skin  is 
usually  blue  and  livid,  and  the  temperature  is  much  below  that  of  the 
healthy  limb.  These  deformities  randy  disappear,  but  continue  through 
life,  which  is  in  no  way  shortened  bv  the  disease.  The  following  cases 

»'  c? 

may  be  presented  to  illustrate  the  appearance  and  behavior  of  the  disease. 
1  he  first   case  is  somewhat  anomalous,  as  there  were  two  forms  of  para- 

1  Sammlung  Klinischer  VJ>rtrage,  Heft  1,  1870. 

2  Produced  by  attempts  to  restore  disturbed  equilibrium. 


ANTERO-SPINAL    PARALYSIS    OF    INFANCY.  241 

lysis  ;  the  primary  attack  being  hemiplegia,  and  the  secondary  para- 
plegia : — 

CASE  I Robert  B.  (a  seventh-month  child)  was  sent  to  me  by  Dr.  H. 

G.  Piffard,  of  this  city.  During  September,  1876,  he  became  feverish, 
and,  after  two  days,  during  which  he  was  confined  to  bed,  he  had  a  general 
convulsion.  Before  his  fever  he  had  eaten  a  great  quantity  of  cherries, 
and  his  mother  supposed  his  illness  to  be  due  to  this  cause.  The  mother 
stated  that  the  convulsion  lasted  three  and  a  half  hours.  He  became  para- 
lyzed two  days  afterwards,  the  right  arm  and  leg  being  affected  ;  but 
two  days  after  this  he  could  use  even  these  limbs.  A  few  days  subse- 
quently lie  went  out  to  play,  but  came  back  feeling  out  of  sorts  ;  and,  after 
u  few  hours'  fever,  another  spasm  took  place.  Within  the  next  thirty -six 
hours  both  legs  were  paralyzed,  so  that  he  could  not  stand.  Towards  the 
first  of  November  he  regained  some  power,  and  can  now  stand  when  hold- 
ing a  chair. 

Present  Condition — He  is  a  puny  boy,  about  five  years  old,  and  is  badly 
nourished.  He  has  no  voluntary  power  over  lower  extremities,  but  can 
move  the  arms  perfectly.  The  legs  are  both  very  much  reduced  in  size, 
and  the  muscles  are  flabby  and  atrophied.  The  peronei,  solei,  and  ante- 
rior tibial  muscles  are  reduced  in  size,  and  have  lost  their  electric  con- 
tractility. He  perceives  pinches,  and  changes  of  temperature,  and  the 
"  wire-brush"  produces  much  pain.  The  skin  is  cold,  mottled,  and  dry, 
and  here  and  there  is  dotted  with  patches  of  scurfy  eruption. 

CASE  II Annetta  F.,  aged  10  years.  About  three  years  ago  she  be- 
came quite  ill  after  a  sleigh  ride,  and  it  was  supposed  that  she  had  "  caught 
cold."  Her  feverish  symptoms  were  quite  decided,  and  she  was  slightly 
delirious.  After  several  days  she  seemed  to  improve  slightly,  but  on 
awaking  one  morning  it  was  found  that  she  was  paralyzed  and  unable  to 
rise  ;  and  she  complained  of  intense  backache  and  tingling  of  the  limbs, 
which,  however,  were  of  very  short  duration.  About  two  months  after  this 
she  began  to  recover  the  use  of  her  arms,  but  the  legs  were  more  fully 
paralyzed ;  and  it  was  several  months  before  she  began  to  move  her 
toes,  and  finally  make  feeble  movements  of  a  more  extended  character. 
The  muscular  contractions  of  the  flexors  were  performed  more  easily  than 
movements  requiring  extension  ;  and,  after  a  time,  she  attempted  to  walk, 
but  at  first  this  act  was  impossible.  During  the  next  year  she  was  obliged  to 
use  crutches,  and  needed  the  assistance  of  her  nurse.  When  I  saw  her, 
there  was  talipes  equinus  varus  of  the  left  foot,  while  the  right  seemed  to 
be  but  little  affected.  Flexion  was  possible,  but  extension  of  the  leg  or 
foot  was  beyond  her  power.  There  was  some  relaxation  of  the  ligaments  of 
the  knee-joint,  so  that  when  I  made  extension  I  caused  the  tibia  to  form 
an  obtuse  angle  with  the  femur,  so  that  there  was  some  anterior  curvature. 
Her  gait  was  peculiar,  and  she  swung  the  left  leg,  bringing  it  down  with 
a  jerk.  The  skin  covering  the  left  leg  was  dusky  and  mottled,  and  seemed 
in  close  contact  with  the  tissue  beneath ;  and  the  surface-temperature  was 
several  degrees  below  that  of  the  other  side.  No  rectal  trouble. 

CASE  III — A  girl  sent  to  me  by  Dr.  Lockwood,  of  Xorwalk,  had  pre- 
sented, among  other  symptoms,  mitral  disorder,  fever,  general  paralysis, 
residual  paralysis,  paraplegia,  and  paralysis  and  atrophy  of  the  right  deltoid, 
which  cannot  be  made  to  contract  when  subjected  to  either  current.  Right 
leg  more  affected  than  the  left. 

CASE  IV A  girl  10  years  of  age.  At  the  second  year  after  a  fall  she 

became  feverish,  was  delirious,  and  took  to  her  bed.  There  was  general 
16 


242  DISEASES    OF    THE    SPINAL    CORD. 

paralysis  of  the  right  leg  and  thigh  ;  but  after  three  months  there  was  im- 
provement, except  of  the  leg,  which  remained  paralyzed.  There  are  now 
a  pronounced  talipes  varus,  complete  atrophy  ot  the  anterior  muscles,  ami 
utter  loss  of  electro-muscular  contractility.  She  has  used  various  forms  of 
orthopa-dic  apparatus  without  relief. 

CASK  V. — Frank  N.  C.,  4  years  old,  a  stout,  rugged  boy,  enjoyed 
good  health  until  January,  1H77,  when  he  contracted  scarlet  fever,  with 
albiimiiiuria  as  a  result.  From  this  he  recovered,  but  in  August  he  again 
fell  sick  with  what  was  pronounced  to  be  rheumatic  fever.  There  were 
high  temperature,  some  diarrhoea,  which  lasted  for  a  number  of  days,  pain- 
ful joints,  and  loss  of  power  in  both  lower  extremities.  The  power  re- 
turned in  the  right  leg,  so  that  by  the  middle  of  September  (three  weeks 
from  the  invasion  of  the  fever)  lie  had  control  of  that  member.  The  left 
remains  powerless,  and  there  has  been  slow  atrophy.  The  extensors  of 
the  leg  and  foot  are  now  powerless,  and  there  is  decided  atrophy  of  thcM- 
and  the  posterior  tibial,  adductors  of  the  thigh  and  anterior  muscles.  The 
knee-joints  are  quite  weak,  and  there  are  projections  on  the  inner  side  of 
both  knees.  He  is  knock-kneed,  no  eversion  or  inversion  of  feet,  but 
there  is  slight  talipes  of  the  left  foot. 

CASE  VI — Mamie  AV.,  6  years  and  1  month  old,  always  was  a  nervous, 
excitable  child.  Has  had  several  convulsions  in  her  life  of  an  epileptic 
character,  without  any  after-effects,  or  apparent  coexisting  disease.  In 
July  last  she  had  whooping-cough.  On  September  4th  she  was  taken 
with  colic,  malaise,  and  convulsions,  during  which  the  body  became  rigid, 
and  she  frothed  at  the  mouth.  These  convulsions  appeared  at  5  P.  M., 
and  lasted  until  midnight.  She  was  unconscious  all  the  time.  At  7  P.  M. 
the  corner  of  the  mouth  became  drawn  up  by  spasms.  She  had  fever  dur- 
ing the  following  day  and  for  a  number  of  days.  Did  not  make  any 
attempts  to  move  for  a  number  of  days,  and  for  twelve  days  she  could  not 
speak.  She  was  found  to  be  generally  paralyzed,  and  after  a  short  time 
the  arms  recovered  their  strength,  but  the  legs  began  to  lose  their  size  and 
shape,  and  became  smaller  than  they  were  before.  Her  mental  condi- 
tion is  defective  (five  weeks  after  attack).  And,  though  there  is  no 
impairment  of  bladder  or  rectum,  she  does  not  call  attention  to  her  wants, 
but  defecates  and  urinates  in  her  clothing.  Power  of  upper  extremities 
good.  The  legs  are  cold  and  mottled  ;  there  is  slight  talipes  on  both  sides; 
and  great  wasting  of  the  flexors  of  the  feet,  especially  of  the  right.  Faint 
contractions  are  excited  by  the  strongest  faradic  currents,  but  she  can 
move  her  toes  very  feebly,  but  not  flex  the  foot.  She  has  control  over 
the  thighs.  I?oth  feet  are  slightly  everted.  There  is  redness  of  the  skin 
covering  the  right  knee,  but  no  pain;  no  pain  in  back;  slight  impairment 
of  sensation,  but  reflex  irritability  not  embarrassed,  as  was  demonstrated 
by  pinching;  pupils  moderately  dilated. 

The  muscles  of  the  leg  are  more  often  affected  than  those  of  any  other  part. 
In  nearly  every  instance  the  tibiaJis  anticus  is  paralyzed,  and  in  18  of  the 
23  examples  I  have  noticed  this  muscle  was  affected.  The  peroneus  ter- 
tnis,  lonrjus;  ertensores  longi  dif/itornm,  proprius  pollicis;  and  the 
Jieroreg  longi  digitorum,  and  longus  pollicis,  are  usually  affected.  The 
deltoid  is  paralyzed  more  rarely,  and  of  the  cases  I  have  enumerated  there 
were  but  two  in  which  this  muscle  was  affected.  The  muscles  of  the  up- 
per extremities  are  seldom  involved  in  comparison  with  those  of  the  leg, 
and  those  that  are  usually  paralyzed  are  the  flexors  of  the  hand.  Though 


ANTERO-SPINAL   PAKALYSIS    OP    INFANCY.  243 

the  muscles  of  the  trunk  may  be  sometimes  involved  in  the  early  paralysis, 
it  is  extremely  rare  that  we  find  any  residual  paralysis  of  any  of  them. 

Causes — The  etiology  of  the  affection  is  anything  but  clear.  Expo- 
sure and  bad  or  insufficient  food  are  supposed  to  account  for  it,  just  as  they 
do  for  many  other  diseases  of  the  same  class.  It  is  a  significant  fact  that 
more  of  these  patients  belong  to  the  lower  walks  of  life  than  to  the  higher, 
and  that  the  children  of  the  destitute  poor  who  come  of  drunken  parents, 
and  are  "  knocked  about"  and  half-fed,  are  those  who  are  generally  the 
victims  of  the  disease.  As  to  age,  Sinkler  has  found  that  84  of  108  cases  were 
between  the  ages  of  six  months  and  three  years,  and  that  half  of  this  num- 
ber were  males.  Duchenne1  holds  that  two-thirds  of  the  cases  begin  before 
the  second  year,  which  view  I  am  disposed  to  take.  Warm  weather  seems 
to  favor  the  development  of  the  disease,  and  in  nearly  two-thirds  of  Sink- 
ler's  cases  the  disease  began  in  the  months  between  May  and  October. 
Cases  have  been  reported  in  which  the  exanthemata  have  preceded  the 
paralysis,  and  varicella,  measles,  and  scarlatina  may  be  mentioned  among 
these;  but  it  is  probable  that  in  the  majority  of  such  cases  sclerosis  not 
limited  to  the  anterior  columns  has  been  the  central  condition. 

Morbid  Anatomy  and  Pathology — We  are  indebted  to  Charcot2 
and  Jotiroy,  Duchenne,3  Echeverria,*  and  others  for  reports  of  autopsies 
and  microscopical  examinations,  and  as  the  result  of  their  investigations 
the  following  appearances  may  be  looked  for. 

In  the  early  stages  of  the  disease  there  is  probably  a  condition  of  sub- 
acute  myelitis,  with  softening  and  destruction  of  nerve-elements,  etc.  This 
is  confined  exclusively  to  the  anterior  horns.  Some  of  the  nerve-cells  of 
this  portion  of  the  cord  are  sometimes  filled  with  granular  pigment  deposits, 
while  others  are  disorganized  and  broken  up.  The  nerve-tubes  of  the 
anterior  roots  will  be  found  shrunken,  the  myeline  absent,  but  the  axis 
cylinder  is  nearly  always  intact. 

In  other  cases  of  longer  standing  there  are  evidences  of  atrophy  of  the 
anterior  horns,  perhaps  amyloid  degeneration,  and  sometimes  sclerosis. 
The  nerve-cells  are  found  in  an  atrophic  condition,  or  absent  altogether. 
The  white  matter  of  the  anterior  and  lateral  columns  is  not  rarely  the 
seat  of  such  degeneration,  and  proliferation  of  the  connective  tissue  is 
sometimes  found.  In  25  cases,  collected  by  Seguin,5  the  constancy  of  the 
lesion  is  very  clearly  shown. 

The  anterior  horns  together  were  affected  in          .         .         .11  cases. 
The  right  anterior  horn  alone  was  affected  in        .         .     .  * .       1  case. 
The  left          "          ««»**«  ...       4  cases. 

Both  affected  in 6     " 

Sclerosis  of  antero-lateral  columns  (chiefly)  and  other  white 

matter .         .  13     " 

Tubercules  and  blood-clots  .         .         .         .         .  2     " 

Meningitis  and  meningeal  congestion    .         .         .  •'  ^  .         .       2     " 

1  De  1' Electrisation  localise,  3d  ed.,  Paris,  1872,  p.  417. 

2  Arcliiv.  de  Phys.,  tome  iii.  1870.  3  Ibid.,  tome  iv.  1870. 

4  Reflex  Paralysis,  etc.,  p.  29,  ISTew  York,  18G6. 

5  Spinal  Paralysis,  etc.,  pp.  12-13. 


244  DISEASES    OF    THE    SPINAL    CORD. 

Dumaschino1  and  Roger,  Cornell,*  Clarke,8  Charcot,4  and  Joffroy  have 
udded  many  histories  to  those  given  to  the  profession  by  the  early  writers, 
and  it  is  now  well  settled  that  the  anterior  horns  and  lateral  columns  are 
the  seats  of  the  central  lesion. 

Rosenthal5  considers  that  the  primary  cause  is  dilatation  and  thickening 
of  the  vessels,  and  does  not  believe  that  the  morbid  process  begins  by 
degeneration  of  the  nerve-cells.  Notwithstanding  the  appearance  of  well- 
defined  lesions  in  nearly  every  case,  there  are  occasional  examples  of  the 
disease  where  no  central  changes  are  to  be  found.  Ke"tli6  reports  one  of 
these  in  which  extensive  muscular  alterations  were  visible,  but  not  the 
slightest  indication  of  central  disease.  Elischer7  examined  the  muscl«  •-, 
which  were  seen  to  be  the  seat  of  both  fatty  and  colloid  degeneration. 
The  sareolemma  and  nerves  were  not  altered.  In  the  striated  muscles, 
instead  of  the  single  normal  cell-nucleus,  there  were  seen  three  or  four 
granular  cell-nuclei,  which  seemed  to  be  at  the  same  time  enlarged,  and 
contained  two  or  three,  or  even  more  nucleoli.  The  contractile  material 
was  diminished,  so  that  it  did  not  fill  out  the  sheath,  but  drew  away  from 
it.  This  atrophy  was  so  great  that  at  the  upper  and  under  part  of  the 
spindle-shaped  cell-nucleus  of  the  sheath  there  was  hardly  to  be  found  a 
breadth  of  .002  millimetre  of  cross-striped  contractile  muscular  substance. 
Ke"tli  thinks  that  these  changes  in  the  muscle  without  central  disease  point 
to  the  peripheral  nature  of  the  affection,  in  which  opinion  he  has  but  few 
followers.  Lesions  of  peripheral  nerves  have  been  found  by  various 
observers.  Rinecker8  reports  an  autopsy,  made  by  Forster,  in  which 
these  nerves  were  found  to  be  thin,  shrunken,  and  greatly  degenerated. 
The  bones  and  muscles  present  appearances  which  are  perhaps  more  inte- 
resting than  those  of  the  cord. 

The  muscular  fibres  are  at  first  found  to  be  reduced  in  size,  and  subse- 
quently the  transverse  striae  gradually  disappear,  while  the  longitudinal 
fibres  become  more  marked.  There  is  a  marked  increase  in  the  connective 
tissue,  and  next  a  fatty  degeneration,  the  oil-globules  taking  the  place  of 
the  normal  muscular  tissue,  and  finally  nothing  remains  but  the  connective 
tissue  and  fat,  which  latter  disappears,  leaving  the  sarcolemma  bound 
together  by  connective  tissue. 

The  accompanying  cuts,  from  Duchenne,  show  the  changes  that  take 
place. 

The  bloodvessels  running  to  the  atrophied  muscles  are  often  of  smaller 
size  than  they  should  be,  and  sometimes  are  the  subject  of  atheromatous 
degeneration. 

The  bones  also  undergo  atrophic  changes,  becoming  friable  and  thin, 

1  Gnz.  M6d.  de  Paris.  1H71.  *  Ibid.,  1864,  p.  290. 

3  Mfd.-Chir.  Trans.,  vol.  ii.  1869,  p.  249. 

4  Op.  cit.  6  Quoted  by  Fox,  op.  fit.,  p.  290. 
6  H'i'l.                                                             7  11,1,1. 

»  Jsihrs.  ftlr  Kinderlu'ilkundc,  1871,  5  Heft  1. 


ANTERO-SPINAL    PARALYSIS    OF    INFANCY. 
Fig.  31. 


245 


a.  Normal  fibre. 

A.  Represents  the  normal  fibres  with  well-marked  transverse  striae.     B.  The  transverse  striae 
are  not  quite  so  distinct,  but  the  longitudinal  fibres  are  well  marked. 


Fi<r.   32. 


Fiji.  33. 


x\^ 


a.  Fat  cells.    6.  Interstitial  fatty  deposits. 

The  stage  of  fatty  degeneration.  A.  The  lon- 
gitudinal fibres  are  only  seen,  and  there  is  a  de- 
posit of  round  and  oval  adipose  cells  and  oil-glo- 
bules. B.  Undulations  of  longitudinal  fibres. 


a,  a.  Fat  molecules. 

The  progressive   fatty  degeneration  and 
the  disappearance  of  longitudinal  fibres. 


This  illustration  represents  the  final  stages,  iu  which  it  will  be  seen  that  the  muscular  fibre  has 
lost  its  identity,  and  at  last  there  is  an  absence  even  of  oil-globules. 

and  occasionally  the  seat  of  fatty  degeneration.     The  cartilage  covering 
their  articular  extremities  is  roughened,  and  in  some  places  detached. 

Though  some  observers  have  maintained  the  peripheral  origin  of  the 
disease,  the  large  majority  have  adopted  Heine's  original  views  advanced 


246  DISEASES    OF    THE    SPINAL    CORD. 

in  1840,  and  endorsed  by  Duchenne  in  1855.  The  almost  general  opinion 
that  the  disease  is  of  central  origin  has  been  conclusively  proved,  I  think, 
by  the  large  number  of  autopsies,  the  most  valuable  of  which  have  been 
made  in  late  years. 

"NVestphal's  views  in  regard  to  the  existence  of  trophic  cells,  which  were 
also  adopted  by  Duchenne,  certainly  receive  decided  confirmation  in  the 
constant  atrophic  processes  which  are  connected  with  degeneration  of  the 
cells  of  the  anterior  horns. 

That  it  is  not  a  disorder  dependent  upon  the  sympathetic  system  has 
been  proved  by  the  utter  absence  of  any  diseased  condition  either  of  the 
ganglia  or  the  nerves. 

Diagnosis. — The  existence  of  febrile  symptoms,  and  the  secondary 
complete  paresis  which  changes  its  character  and  is  finally  confined  to  a 
few  muscles,  the  unimpaired  .sensibility,  and  the  rapid  sequence  of  atrophy 
and  deformities  give  this  disease  a  distinct  character  which  does  not  ad- 
mit of  any  mistake  in  diagnosis.  Forms  of  reflex  irritation,  such  as  asca- 
rides,  adherent  prepuce,  and  like  peripheral  conditions  may  produce  some 
of  the  symptoms,  but  their  non-progressive  character,  and  disappearance 
with  the  removal  of  the  cause,  should  make  the  possibility  of  an  error  very 
remote. 

Prognosis. — Much  depends  upon  the  behavior  of  the  muscles  under 
electrical  stimulus.  If  the  least  response  either  to  the  galvanic  or  faradic 
currents  can  be  recognized,  the  chances  are  extremely  good,  and  it  only 
remains  for  the  physician  to  be  patient  and  attentive.  In  regard  to  dura- 
tion and  its  bearing  upon  prognosis,  I  may  state  that  many  cases  have 
Ix-en  cured  even  after  deformities  have  taken  place.  Klopsch,1  of  lires- 
lau,  reports  several  of  these  cases.  In  one  there  was  shortening  of  the 
thigh  and  deformity  of  the  pelvis,  as  well  as  other  serious  troubles.  Much 
of  the  hope  of  cure,  however,  depends  upon  the  care  taken  in  the  treat- 
ment. 

Treatment — The  most  active  and  useful  agent  in  the  therapeusis  of 
this  disease  is  undoubtedly  electricity,  either  as  galvanism  or  faradism,  ap- 
plied to  the  muscles.  The  treatment  of  the  central  lesion  is  also  of  im- 
|w>rtance,  and  it  is  advisable  to  begin  an  energetic  course  of  bromides  and 
ergot,  with  the  actual  cautery,  before  the  atrophic  condition  commences. 
After  this  the  central  disease  is  very  difficult  to  manage.  Heine  recom- 
mended strychine  (FF.  «,  1),  10,  32,  40,  42),  which,  in  young  children, 
may  be  given  in  doses  of  -,  ^Oth  of  a  grain,  and  afterwards  increased.  Cod- 
liver  oil  and  sea-air,  good  food,  and  tonics  are  of  as  much  importance  as 
anything  else. 

AN  hen  we  come  to  the  treatment  of  the  paralyzed  muscles,  we  may  try 
electricity,  massage,  hypodermic  injections  of  strychnine,  and  the  applica- 
tion of  heat  and  cold.  If  the  faradic  current  be  found  to  be  incapable  of 
producing  contractions  of  the  paralyzed  muscles,  we  must  make  use  of  the 

1   Ullsburger's  Prize  Essay,  Am.  Journ.  ot'Obstet.,  1870-71. 


ANTERO-SPINAL    PARALYSIS    OF    ADULTS.  247 

galvanic  current.  From  ten  'to  thirty1  cells  of  any  good  galvanic  battery 
should  be  employed,  and  the  electrodes  must  be  covered  with  sponge  or 
cloth.  When  the  positive  electrode  is  placed  in  the  groin  (if  the  legs  are 
paralyzed),  and  the  negative  over  the  muscle  or  muscles  paralyzed,  a  con- 
traction may  be  seen  ;  if  such  does  not  take  place,  the  current  may  be 
slowly  intermitted  by  proper  apparatus,  or  by  simply  removing  the  sponge 
from  the  surface  and  reapplying  it  again.  If  the  current  be  too  strong,  or 
if  the  application  be  too  protracted,  we  may  be  disappointed,  for  the  small 
amount  of  electric  irritability  that  exists  may  be  quenched  before  an  ap- 
preciable contraction  is  perceived.  It  is  therefore  better  to  use  a  current 
of  low  tension.  If  we  are  gratified  by  the  appearance  of  a  contraction,  we 
should  produce  two  or  three  more  and  then  stop  for  the  day.  By  increas- 
ing the  muscular  stimulation  little  by  little  each  day,  we  may  finally  create 
powerful  contractions  with  a  minimum  current,  and  after  a  short  time  we 
may  substitute  the  faradic  current.  It  is  of  great  importance  that  muscular 
relaxation  should  be  produced  during  the  use  of  electricity.  I  may  repeat 
what  I  have  already  said,  and  add  that  a  tired  muscle  naturally  responds 
less  perfectly  to  electric  stimulation  than  one  which  is  unimpaired.  If 
massage  is  used,  it  is  well  to  knead  and  rub  each  muscle  every  day. 

Should  electricity  fail  to  relieve  the  contracted  condition  of  the  limbs, 
which  may  be  present,  we  may  avail  ourselves  of  the  knife.  Tenotomy 
is  often  of  service,  but  it  should  not  be  prematurely  resorted  to,  but  left 
as  a  last  resource  when  all  other  remedies  fail. 

Volckman  speaks  in  glowing  terms  of  the  use  of  Junot's  boot,  which, 
with  the  rubber  muscle  of  Sayre,  and  the  plaster  bandage,  is  a  useful  form 
of  treatment  in  these  ancient  cases.  The  paralyzed  limb  is  placed  in  the 
boot  and  the  air  exhausted,  so  that  a  determination  of  blood  to  the  part 
shall  be  induced. 


ANTERO-SPINAL  PARALYSIS  OF  ADULTS. 

Synonyms Acute  anterior  spinal  paralysis.  Subacute  general  ante- 
rior spinal  paralysis  (Duchenne).  Spinal  paralysis  of  adults  (Meyer. 
Charcot,  Gombault).  Myelitis  of  the  anterior  horns  (Dujardin-Beau- 
metz,  Seguin).  Acute  spinal  paralysis  of  adults  (Petitfils).  Anterior 
poliomyelitis  (Erb,  Eisenlohr).  Acxite  anterior  poliomyelitis  (Kussmaul). 

Definition — A  myelitis  of  the  anterior  horns  of  the  spinal  cord,  either 
symptomatized  by  an  acute  invasion  attended  by  fever,  and  followed  by 
sudden  paralysis,  or  by  the  gradual  appearance  of  the  paralysis  which  be- 
comes complete  and  next  partially  disappears,  leaving  certain  muscles 
affected ;  unattended  by  loss  of  sensation,  or  vesical  and  anal  trouble. 

Symptoms I  am  indebted  to  the  little  memoir  of  Dr.  E.  C.  Seguin 

for  assistance  in  the  preparation  of  this  article,  and  for  the  report  of  a 

1  It  will  rarely  be  found  necessary  to  use  this  number,  and  it  is  advisable  to 
begin  with  the  weakest  current  that  will  provoke  contractions. 


248 


DISEASES    OF    THE    SPINAL    CORD. 


Fig.  35. 


case  which  afterwards  fell  under  my  observation  when  I  followed  him  :is 
visiting  physician  to  the  Epileptic  and  Paralytic  Hospital.  Duchemic1 
first  called  attention  to  this  form  of  paralysis  as  early 
as  lHf)3,  and  recognized  its  identity  with  infantile 
paralysis.  In  18f>3  Charcot*  was  struck-  with  the 
similitude  between  the  two  diseases,  and  in  1872— 
73  and  later  years  Gombault,8  Dujardin-Beau- 
metz,4  Petitfils,6  and  Bernhardt6  have  presented 
cases,  and  decided  the  fact  that  infantile  paralysis 
had  an  analogue  in  adult  life.  Gombault  brought 
forward  the  first  case  with  an  autopsy  confirming 
the  theory  enunciated  by  Duchenne.  In  this  coun- 
try Hammond7  has  written  quite  fully,  and  later  the 
admirable  little  works  of  Seguin  epitomize  all  that 
has  already  been  brought  forward.  The  first  case 
seen  by  Seguin8  has  since  fallen  under  my  observa- 
tion, and  from  his  published  notes  I  copy  her  his- 
tory. 

Female,  unmarried,  aged  twenty  years.  Admit- 
ted to  the  Epileptic  and  Paralytic  Hospital,  Black- 
well's  Island,  service  of  Dr.  E.  C.  Seguin,  Novem- 
ber, 1H71.  Patient  presents  a  paralyzed  and  ex- 
tremely atrophied  left  leg,  and  gives  the  following 
imperfect  history  :  The  trouble  began  nine  months 
ago,  suddenly  during  sleep,  with  painful  contrac- 
tions :  she  then  gradually(?)  lost  power  in  the  left 
leg :  no  other  limb  affected.  The  patient  cannot  state  how  long  a  time 
elapsed  between  the  first  symptom  and  the  discovery  of  palsy.  She  adds 
that,  on  the  day  before  the  attack,  her  left  leg  felt  quite  cold  and  a  little 
numb  ;  and  that  her  menses  were  suppressed.  No  cause  is  apparent — no 
hereditary  influence,  no  injury. 

Examination  :  Left  foot  is  drawn  up  in  moderate  pes  eqmnns,  with 
inward  inclination.  No  voluntary  movements  below  the  knee.  The 
patient's  answers  to  the  festhesiometer  test  are  unreliable  ;  sensibility  to 
painful  impressions  is  somewhat  impaired,  that  to  temperature  preserved  ; 
tickling  is  felt  equally  on  both  feet.  Pressure  shows  tenderness  over  the 
lumbar  vertebra; ;  no  spontaneous  pain.  The  right  calf  measures  2(5.0  c. 
in  circumference,  the  left  23.7  c.  There  is  absolute  loss  of  electro-mus- 
cular contractility  in  all  the  muscles  of  left  leg.  The  left  leg  is  very  cold, 
and  its  circulation  feeble.  I  frequently  called  the  attention  of  the  resident 


Antero-spinal    Paralysis. 
(Seguin.) 


1  Do  1* Electrisation  localises,  Paris,  1X72,  p.  437  et  seq. 

1  Tapers  of  Petitttls. 

1  Arcliiv.  de  Physiol.  Norm,  et  Path.,  1873,  pp.  80-87. 

4  DC  la  my&litp  aiglie,  Paris,  1H7'2. 

8  Consideration  sur  1'atropliie  aiglie  des  cellules  mortrices,  Paris,  1873. 

'  Arch.  fUr  Psych,  mid  Nervenkrank.,  1874. 

7  Diseases  of  Nervous  System,  N.  York,  1877,  p.  470  et  seq. 

8  Spinal  Paralysis,  N.  York,  1874,  and  Anterior  Myelitis,  1877. 


ANTERO-SPINAL    PARALYSIS    OP    ADULTS.  249 

staff  and  of  friends  to  this  remarkable  case  as  one  of  the  same  kind  as  that 
which,  occurring  in  the  early  years  of  life,  we  call  infantile  spinal  palsy. 

The  subsequent  history  need  not  be  reported.  No  treatment  did  any 
good  ;  the  girl  remained  in  the  hospital  without  any  active  symptom,  and 
went  away  October  3,  1873,  carrying  this  wasted  left  leg.  She  was  em- 
ployed as  a  help  in  the  wards  of  the  Convalescent  Hospital  on  Hart's  Island, 
and  was  there  much  exposed  to  cold. 

The  second  attack,  of  which  patient  gives  a  good  account,  came  on  late 
in 'December,  1873.  Had  pains  "like  rheumatism"  in  right  leg;  there 
was  a  feeling  of  pins  and  needles  in  the  limb,  this  numbness  extending 
above  the  knee.  She  is  positive  that  on  the  fourth  day  the  right  leg  was 
completely  paralyzed.  No  symptoms  in  left  leg.  No  bedsore,  and  no 
affection  of  bladder  or  rectum.  Re-admitted  to  the  Epileptic  and  Para- 
lytic Hospital,  March  3,  1874,  with  atrophy  and  palsy  of  both  legs  ;  no 
acute  symptoms. 

During  the  spring  and  summer  this  patient  rather  gradually  lost  strength 
in  the  thighs,  in  the  right  most.  She  also  exhibited  a  variety  of  interest- 
ing visceral  disturbances,  consisting  of  amenorrhoea,  lasting  two  and  three 
months;  the  menses  then  appearing  with  much  pain,  the  blood  "abundant 
and  in  clots ;  there  were  also  pains  in  the  back  and  lower  abdomen.  On 
many  days  in  this  period  the  urine  had  to  be  drawn  off  with  the  catheter, 
and  it  often  was  bloody,  exhibiting  a  heavy  mucous  deposit,  and  contain- 
ing albumen.  The  microscope  showed  only  leucocytes  and  a  variety  of 
epithelial  cells — there  being  probably  both  pyelitis  and  cystitis.  Since 
the  middle  of  September  has  not  required  the  catheter,  and,  with  excep- 
tion of  palsy,  has  been  better. 

Re-examined  October  25,  1874.  Patient,  when  she  first  came  in  this 
year,  walked  ill  with  a  crutch  and  stick ;  is  now  able  to  walk  with  two 
sticks  (result  of  education).  Cannot  stand  or  walk  without  help.  The 
patient  is  a  stout  and  healthy  girl,  exhibiting  nothing  abnormal  above  the 
hips.  Both  lower  extremities  are  extensively  palsied  and  much  wasted. 
The  left  leg  (first  attacked  in  1871)  shows  no  voluntary  movement  below 
the  knee,  with  exception  of  slight  separation  of  the  toes.  As  the  patient 
lies  on  the  bed  she  is  able  to  raise  the  extended  limb  as  a  whole ;  but 
the  strength  at  knee-joint  is  small.  The  thigh  is  thin  and  flabby  ;  the  leg 
is  the  seat  of  extreme  atrophy,  and  looks  just  like  the  same  part  in  cases 
of  infantile  spinal  palsy,  there  being  apparently  only  connective  tissue  and 
fat  around  the  bones,  the  skin  being  bluish  and  very  cold  to  the  touch. 
The  right  lower  extremity  (paralyzed  in  1873)  is  in  a  very  similar  though 
less  extreme  state.  All  voluntary  movements  are  possible  with  the  foot, 
though  they  are  feebly  performed.  The  limb,  as  a  whole,  cannot  be  raised 
from  the  bed,  and  flexion  at  knee-joint  is  weak.  The  quadriceps  exten- 
sor femoris  is  wholly  paralyzed  ;  the  flexors  of  the  thigh  upon  the  body  act 
feebly  ;  the  adductors  fairly.  Both  feet  lie  extended  and  adducted  ;  toes 
flexed.  The  right  leg  is,  like  the  left,  extremely  wasted,  bluish,  and  quite 
cold.  Sensibility  to  contact,  pain,  and  temperature  are  preserved  in  both 
limbs.  Tickling  is  felt,  but  produces  no  reflex  movement  in  the  palsied 
parts.  The  electro-muscular  reaction  of  the  atrophied  muscles  of  both 
limbs  is  lost  (both  currents).  At  present,  urine  is  passed  normally.  The 
patient's  arms,  shoulders,  and  chest  are  large  and  rounded,  standing  in 
remarkable  contrast  to  the  dwindled  legs.  There  have  been  no  bedsores 
and  no  spinal  epilepsy. 


250  DISEASES    OF    THE    SPINAL    CORD. 

Circumference  of  right  thigh  (lower  third)         .         .         .  31.5  c. 

"  left       "         "         "  ...  30.5 

"  right  calf      • 24.0 

left       " 21.5 

"  forearms 25.0 

On  a  healthy  girl  (non-palsied)  of  same  proportions  as  the  patient  the 
following  measurements  are  obtained  : — 

Circumference  of  right  calf      ......    35. Oc. 

"  left        " 34.5 

"  forearms        .         .         .         .         .         .24.0 

The  patient  having  been  in  bed  some  time,  well  covered  up,  has  a  ther- 
mometer held  between  the  great  and  second  toes  of  each  foot  for  three 
minutes,  with  results:  Right  side,  84.25°  Fahr. ;  left  side,  86°  Fahr. 

In  March,  1876,  the  patient  came  under  my  charge,  when  I  found  that 
her  condition  was  somewhat  aggravated.  She  manages  to  go  about  with 
the  aid  of  crutches,  but  has  utter  loss  of  power  below  the  knees.  .The  tac- 
tile sensibility  is  much  lowered,  and  tickling  can  be  borne  without  any 
reflex  movement  being  produced,  and  she  has  lost  control  to  a  great  ex- 
tent over  the  bladder  and  rectum. 

Another  case  reported  by  Lincoln  is  well  worth  presenting  as  illus- 
trative of  this  form  of  disease  beginning  without  fever. 

A  tall,  stout  man,1  49  years  of  age  and  of  previous  good  health,  noticed 
one  morning,  without  any  previous  symptoms,  a  feeling  in  his  legs  as  if 
they  had  fallen  asleep.  The  feeling  came  on  again  and  again  through  the 
day,  and  he  began  to  be  a  little  weak  in  the  legs.  In  the  afternoon,  when 
trying  to  step  upon  the  platform  of  a  street  car,  he  failed,  and  had  to  be 
helped  in.  On  arriving  home,  he  was  able  (with  assistance)  to  walk  up 
stairs  to  his  bedroom,  and  went  to  bed,  where  he  remained. 

When  seen  by  Dr.  L.,  two  days  later,  he  felt  well,  no  giddiness,  muscles 
of  face  and  eyeballs  under  perfect  control,  pupils  normal  in  size  and  con- 
tracted well,  speech  natural,  vision  and  hearing  without  defect.  The 
bladder  and  rectum  performed  their  functions  normally.  The  senses  of 
touch,  pain,  and  temperature  were  normal  in  the  hands,  and  nearly  so  in 
the  feet.  Heflex  contractions  could  scarcely  be  obtained  from  the  soles. 
There  were  no  abnormal  sensations.  Pulse,  80 ;  temperature,  98°.  No 
albumen  in  the  urine. 

The  muscles  of  the  neck  and  limbs,  except  below  the  knees,  were  gene- 
rally in  a  condition  of  semi-paralysis.  He  lay  on  his  back  almost  help- 
less ;  could  not  raise  his  head  from  the  pillow  without  some  help,  and 
could  not  raise  his  knees  from  the  bed  by  flexing  the  thighs.  The  grasp 
of  his  hand  was  very  feeble  indeed.  There  was  no  paralysis  of  any  mus- 
cle. Below  the  knees  he  seemed  to  have  more  strength.  The  weakness 
was  much  more  marked  on  the  left  than  on  the  right. 

Treatment  consisted  at  first  in  mix  vornica  and  cinchona,  and  subse- 
quently tincture  of  iron  with  strychnia,  and  Horstbrd's  acid  phosphates  of 
lime  and  magnesia.  On  the  fifth  day  of  the  attack,  treatment  by  the 
induced  electric  current  was  begun,  when  it  was  found  that  some  at  least 
of  the  muscles  had  lost  part  of  their  susceptibility  to  this  stimulus.  The 

1  Boston  Medical  and  Surgical  Journal,  March  25,  1876. 


ANTERO-SPINAL    PARALYSIS    OP    ADULTS.  251 

loss  went  on  increasing  until  the  twenty-first  day,  when  the  galvanic  cur- 
rent was  substituted,  a  descending  current  being  applied  to  the  spine,  and 
interrupted  currents  to  the  muscles,  three  times  a  week  ;  the  faradic  cur- 
rent was  also  continued  for  a  few  weeks. 

The  hot-air  bath  to  profuse  perspiration  was  used  just  before  the  appli- 
cation of  the  currents,  together  with  regulated  gymnastic  exercises.  The 
paralysis  of  the  muscles  was  gradually  relieved  under  this  treatment  to  a 
very  considerable  degree.  The  patient's  improvement  was  very  gradual, 
and  it  was  six  months  before  he  was  able  to  ride  out.  He  finally  was  en- 
abled to  attend  to  his  business  pretty  much  as  before  the  attack. 

Other  cases  begin  much  more  slowly,  and  several  of  this  kind  are  re- 
ported by  Duchenne,  but  the  origin  of  the  disease  is  nearly  always  sudden. 
There  may  be  pain  and  dysaesthetic  symptoms,  or  no  warning  at  all,  the 
patient  awaking  in  the  morning  and  finding  himself  paralyzed,  as  was  the 
case  with  Seguin's  patient.  Like  the  infantile  form,  there  may  be  an 
acute  attack  of  fever,  which  may  last  for  several  days,  during  which  there 
is  usually  delirium  or  rigors.  The  paralysis  appears  during  this  time,  and 
may  be  general,  so  that  the  upper  and  lower  limbs  are  affected  and  the 
loss  of  power  is  complete.  The  functions  of  the  bladder  and  sphincter  ani 
ore  always  normally  performed  until  other  parts  of  the  cord  are  affected, 
and  there  is  neither  incontinence  of  urine  nor  involuntary  evacuations. 
At  the  end  of  a  few  weeks  there  is  a  commencing  improvement,  some  of 
the  muscles  regaining  their  lost  power  and  contracting  quickly  under 
electric  stimulus,  while  atrophy  of  those  already  paralyzed  begins  to  take 
place.  The  skin  over  the  paralyzed  limbs  is  quite  cold  and  blue,  and 
there  is  diminution  of  temperature  and  faradic  excitability,  while  ulti- 
mately it  is  impossible  to  provoke  any  response,  and  the  limbs  become 
deformed  and  twisted.  Atrophy  of  deeper  parts  follows,  and  the  bones 
become  reduced  in  size,  while  the  articular  ends  appear  large  in  contrast 
with  the  attenuated  size  of  their  shafts.  Sensibility  is  rarely  disordered, 
though  exceptional  cases  of  anaesthesia  or  hypergesthesia  are  met  with,  but 
after  the  inflammation  has  involved  the  posterior  columns  the  phenomena 
of  general  myelitis  are  presented.  Dysaesthesiae  are  common,  and  the 
patients  complain  of  subjective  cold,  various  pains,  and  the  waist-constrict- 
ing band.  The  muscles  of  the  face,  neck,  chest,  and  abdomen  are  rarely 
affected,  but  the  extremities  remain  deprived  of  pain  after  there  has  been 
a  considerable  retrocession  of  the  original  complete  paralysis.  The  atro- 
phy is  rapid,  and  differs  from  that  of  progressive  muscular  atrophy  in  the 
fact  that  whole  groups  are  affected  at  a  time,  while  the  peculiarity  of  pro- 
gressive muscular  atrophy  is  that  muscles  are  irregularly  affected.  There 
are  never  bedsores. 

Erb1  alludes  to  a  light  variety  of  spinal  paralysis,  which  has  been  de- 
scribed by  Kennedy,  Fry,  and  others.  To  this  variety  has  been  given 
the  name  "  temporary  spinal  paralysis."  The  paralysis  is  characterized 
by  its  brief  duration,  and  may  involve  a  limited  group  of  muscles  or  seve- 
ral groups.  It  would  seem,  therefore,  that  there  are  two  varieties :  the 

1  Ai'chiv  fur  Psychiatric,  Band  v.,  Heft  3. 


252  DISEASES    OP    THE    SPINAL    CORD. 

temjxirary  and  permanent ;  but  Seguin  and  others  have  made  the  classifi- 
cation nettle,  stibacttte,  and  chronic,  which  is  based  rather  upon  the 
variety  of  myelitis  than  the  paralysis.  Duchenne  applies  the  term  sub- 
acute  to  the  former,  which  begins  without  fever,  attacks  the  lower  ex- 
tremities first,  and,  extending  upwards,  involves  the  muscles  of  respiration 
and  deglutition. 

Causes The  same  unsatisfactory  history  of  exposure,  fatigue,  and 

jKM-ipheral  irritation  is  connected  with  the  history  of  this  as  well  as  other 
spinal  diseases.  In  four  of  Seguin's  cases  surface  exposure  to  cold  is  said 
to  have  produced  the  attack,  and  in  three  other  cases  "  refrigeration"  is 
named,  while  in  others  dysentery,  measles,  and  other  acute  diseases  were 
at  the  origin  of  the  trouble. 

As  regards  age  and  sex,  I  can  do  no  better  than  refer  to  the  tables  of 
Seguin.  All  of  the  patients  whose  histories  he  collected  were  of  middle 
age.  "  The  greatest  age  at  the  time  of  seizure  was  62  years,  the  least  18 
years."  Among  17  cases  reported  by  various  observers,  there  were  13 
men  and  4  women. 

Morbid  Anatomy  and  Pathology — But  very  little  light  has 
been  thrown  upon  the  morbid  anatomy  of  the  cord,  which  accounts  for 
this  form  of  paralysis.  Chalret1  and  Gombault*  have  reported  two  cases. 
The  appearances  found  may  be  briefly  enumerated  as  these:  The  horizon- 
tal fibres  which  pass  from  the  anterior  horns  to  form  the  anterior  spinal 
nerve-roots  were  diminished  in  size,  and  the  large  ganglion-cells  of  the 
anterior  roots  were  atrophied,  having  undergone  yellow  pigmentation. 
Some  of  the  nerve-cells  which  had  not  undergone  this  form  of  degeneration 
were  also  reduced  in  size.  This  information  is  very  meagre,  though  these 
two  cases  illustrate  the  pathological  anatomy  of  the  disease.  Charcot  and 
the  majority  of  observers  believe  that  the  situation  of  the  lesion  is  always 
in  the  anterior  horns.  The  only  matter  of  dispute  seems  to  be  whether  or 
not  there  is  primary  degeneration  of  the  cells,  or  an  acute  interstitial  mye- 
litis and  secondary  injury  of  the  nerve-cells.  This  latter  view  is  held  by 
Krb,3  and,  I  think,  is  being  generally  adopted. 

The  muscles  were  found  to  be  in  a  state  of  fatty  granulation,  which  is 
the  case  in  the  infantile  variety.  In  some  respects  the  disease  resembles 
progressive  muscular  atrophy  and  bulbar  paralysis,  the  lesion  being  atrophy 
of  the  motor  and  trophic  cells,  but  it  is  probable  that  the  trophic  cells  are 
primarily  affected  in  these  latter  diseases. 

Diagnosis — Antero-spinal  paralysis  is  likely  to  be  sometimes  mis- 
taken lor  progressive  muscular  atrophy.  If  we  bear  in  mind  its  sudden 
or  almost  sudden  and  complete  origin  ;  the  absence  as  a  rule  of  fibrillary 
tremors  (only  two  eases  which  presented  these  symptoms  having  been  re- 
Ijortwl);  that  the  paralysis  precedes  the  atrophy,  and  retrocedes  after  the 
first  general  attack;  that  electric  irritability  is  primarily  lost ;  and  that  the 
atrophy  involves  the  muscles  of  one  or  more  (usually  two)  limbs,  there 

1  Thfese  (K-  Paris,  1872. 

1  Arclu'v.  dc  Physiol.,  Norm,  et  Path.,  tome  v.  1873.  3  Op.  cit. 


ANTERO-SPINAL    PAEALTSIS    OP    ADULTS.  253 

need  be  no  error  made  in  diagnosis.  Anaesthesia,  incontinence,  and  pa- 
ralysis of  the  sphincter  ani  prevent  it  from  being  confounded  with  general 
myelitis,  these  symptoms  belonging  to  the  latter  in  addition  to  the  loss  of 
power  and  atrophy.  Spinal  congestion  may  sometimes  give  rise  to  some 
of  the  symptoms,  and  Cartwig1  presented  a  case  which  he  called  "  inter- 
mittent," somewhat  resembling  the  lighter  form  of  true  antero-spinal 
paralysis. 

A  sugar-baker,  aged  23,  who  was  exposed  to  great  heat  and  sudden 
changes  of  temperature  while  very  lightly  clothed,  had  suffered  in  his 
eighteenth  year  for  four  or  five  weeks  from  an  attack  of  tertian  ague,  from 
which  he  recovered.  One  day  he  perceived  a  numbness  in  his  legs,  which 
rapidly  attacked  his  arms  also,  and  finally  led  to  complete  paralysis  of  the 
muscles  of  the  neck.  Speech,  deglutition,  and  respiration  were  somewhat 
impeded;  the  muscles  of  the  eye  were  unaffected,  as  were  also  the  alvine 
and  urinary  excretions,  and  sensation.  After  twenty-four  hours  there  was 
a  remission  of  the  symptoms;  first  the  neck  began  to  become  movable, 
then  the  fingers,  arms,  body,  and  finally  the  legs.  All  this  took  place  in 
half  an  hour,  and  was  followed  by  an  increase  of  perspiration.  During 
the  next  twenty -four  hours  the  patient  remained  free  from  paralysis,  but 
was  dull;  after  which,  the  above-described  symptoms  returned.  The 
brain  was  always  free ;  the  cervical  portion,  especially  the  upper,  was  not 
always  equally  affected ;  the  movements  of  the  neck  were  often  free ;  and 
difficulty  in  deglutition  and  respiration,  inequality  of  the  pupils,  and  myo- 
sis,  were  frequently  present.  The  phrenic  nerve  was  always  unaffected. 
When  there  was  not  complete  paralysis,  the  affected  limbs  were  generally 
stiff,  and  there  was  contraction  of  the  predominating  groups  of  muscles ; 
when  complete  paralysis  was  present,  the  muscles  were  soft  and  flabby. 
Electro-muscular  irritability  was  almost  completely  absent  during  the  pa- 
ralysis, and  the  violence  of  the  muscles  varied.  Under  the  use  of  quinine, 
the  patient's  condition  was  on  several  occasions  quickly  improved,  but  he 
was  not  cured.  He  was  under  observation  for  more  than  six  months. 
The  author  believes  that  the  case  was  one  of  masked  intermittent,  and 
that  the  phenomena  were  due  to  hypersemia  of  the  cord  and  occasional 
increase  of  serous  exudation. 

In  spinal  congestion  there  are  no  deformities,  no  atrophy,  and  nearly 
always  vesical  trouble  and  constipation. 

Acute  ascending  paralysis  has  been  described  by  the  French  writers, 
and  resembles  very  closely  certain  forms  of  the  disease  under  consideration. 
In  one  remarkable  case  of  this  kind  reported  by  Desjerine,8  no  morbid  ap- 
pearances were  found  after  death.  A  man  entered  the  hospital  suffering 
from  undefined  pain  in  the  lower  limbs,  and  two  days  after  became  para- 
plegic without  any  loss  of  sensibility.  The  paralysis  rapidly  ascended, 
and,  after  four  days,  he  died;  no  trace  of  disease  after  paralysis  of  the 
respiratory  muscles  could  be  found  except  dilated  vessels. 

Seguin  considers  that  this  involvement  of  the  respiratory  muscles  is  a 
diagnostic  sign. 

1  Centralblatt  f.  d.  Med.  Wiss.,  June  15,  1870. 

2  Archives  de  Physiol.,  etc.,  June,  1876. 


254  DISEASES    OF    THE    SPINAL    CORD. 

Prognosis — Antero-spinal  paralysis  is  not  a  disease  which  is  rapidly 
fatal,  and  many  cases  recover  within  a  short  time  after  the  beginning  of 
the  attack.  I  am  not  disposed  to  think  that  the  lesion  is  an  ascending 
one;  but  rather  that,  if  it  progresses  at  all,  it  involves  the  posterior  parts 
of  the  cord  in  the  majority  of  cases,  and  does  not  spread  longitudinally. 
This  is  probably  the  condition  of  affairs  in  the  case  of  S.  W.  Should  the 
paralyzed  muscles  become  atrophied  to  such  an  extent  that  deformities 
result,  I  think  that  there  is  very  little  hope  for  the  patient.  If,  however. 
the  muscles  can  be  made  to  respond  to  the  galvanic  current,  we  should 
never  be  discouraged. 

Of  the  cases  reported  by  Duchenne,  Meyer,  Hammond,  Bernhardt,  Se- 
guin,  and  others,  I  find  that  of  1C  cases  there  were  but  2  deaths.  In  one 
case  there  was  improvement  in  six  months,  in  another  in  four,  and  in 
others  two,  three,  eleven,  and  twelve.  In  two  cases  the  patients  were 
cured,  and  in  several  there  was  progressive  unfavorable  advancement. 

Treatment. — In  electricity  we  possess  a  remedy  of  the  greatest  value. 
I  have  already  called  attention  to  its  use  in  the  infantile  form  of  the  dis- 
ease, so  there  is  no  need  for  going  into  details.  It  is  well  to  use  both  the 
galvanic  and  faradic  currents,  and  in  the  acute  form  of  the  trouble  we 
should  begin  with  counter-irritation  of  the  spine  as  early  as  possible,  and 
for  this  purpose  may  employ  blisters  or  the  actual  cautery. 

Ergot  and  belladonna  in  rather  full  doses  should  be  employed  in  con- 
junction therewith  (F.  7G).  Seguin  recommends  leeching  and  dry  i-ups. 
which  are  both  excellent. 

Should  the  pain  be  severe,  we  may  use  morphine  by  means  of  the  hypo- 
dermic syringe ;  or  spinal  galvanization.  The  after-treatment  should  be 
with  the  galvanic  current.  Hammond  has  benefited  some  of  his  patients 
by  the  use  of  the  iodide  of  potassium  and  ergot,  but  it  is  probable  that 
ergot  possesses  the  most  value. 


PROGRESSIVE    MUSCULAR    ATROPHY.  255 


CHAPTER    X. 

DISEASES  OF  THE  SPINAL  CORD  (COXTIXCEB). 

PROGRESSIVE  MUSCULAR  ATROPHY. 

Synonyms — Wasting  palsy  ;  Cruveilhier's  paralysis  ;  Progressive 
mnskelatrophie ;  Progressive  muskell'ahmung. 

Definition — This  is  an  essentially  progressive  atrophy  of  certain 
groups  of  muscles.  It  is  not  preceded  by  any  paralysis,  but  followed  by 
loss  of  power,  and  terminates  usually  by  involvement  of  the  respiratory 
nerve-centres. 

Cooke,1  in  179$,  directed  attention  to  a  condition  he  called  "anomalous 
hemiplegia,"  which  was  clearly  progressive  muscular  atrophy,  and  his 
was  probably  the  first  recorded  case.  Bell,2  Abercrombie,3  and  Darwell4 
each  published  cases  which  were  undoubtedly  of  this  kind;  and,  in  1836, 
Mayo5  related  two  cases.  It  was  not,  however,  till  1849,  when  Duchenne 
de  Boulogne6  presented  a  memoir  to  the  Institute  of  France,  entitled 
i'Atrophie  musculaire  avec  transformation  graisseuse,"  that  the  pre- 
sent disease  was  recognized.  In  1853,  Cruveilhier7  described  some  cases 
in  which  the  atrophy  was  general,  all  the  voluntary  muscles  being  affected. 
In  1850—1856,  Aran,8  Duchenne,9  and  Eisenmann10  brought  forward 
additional  facts,  and  the  latter  agreed  with  Cruveilhier  that  the  "nerves 
or  nervous  centres  are  at  fault  anterior  to  the  muscles,  and  that  the 
atrophy  of  the  latter  is  a  secondary  process."  Since  that  time  we  are  in- 
debted to  Roberts11  for  the  most  clear  and  instructive  article  that  has  yet 
been  written. 

Symptoms. — The  appearance  and  progress  of  the  disease  are  most 
gradual.  The  affected  individual  may  first  notice  a  slight  weakness  in 
one  of  the  upper  extremities,  and  if  he  be  a  tailor,  as  was  one  of  my  pa- 
tients, he  finds  difficulty  in  handling  his  shears.  Perhaps  the  first  indica- 
tion of  trouble  which  suggests  to  the  patient  the  commencement  of  the 

1  Cooke  on  Palsy,  p.  31,  1822. 

2  The  Nervous  System  of  the  Human  Body,  London,  1830. 

3  On  the  Brain  and  Spinal  Cord,  p.  419,  Edin.,  1828. 

4  Loud.  Med.  Gaz.,  vol.  vii.  p.  201. 

5  Outlines  of  Human  Pathology,  p.  117,  London,  1836. 

6  ^Jemoires  de  1'Acad.  des  Sciences,  1849. 

7  Archives  Gen.  de  Med.,  May,  1853. 

8  Ibid..  Sept.  1850. 

9  De  1' Electrisation  localise,  Paris,  1850. 

10  Canstatt's  Jahresbericht,  1859. 

11  An  Essav  on  Wasting  Palsv,  London,  1858. 


256  DISEASES    OF    THE    SPINAL    CORD. 

disease,  is  when  the  act  of  writing  is  attempted.  According  to  Roberts, 
the  disease  begins,  in  two-thirds  of  the  cases,  in  the  upper  extremities, 
and  the  muscles  of  the  hands  are  the  first  to  suffer  loss  of  function.  Yn-y 
often  several  muscles  are  affected  together,  and  they  soon  become  agitated 
by  what  are  known  as  Jibrillttry  contractions,  or,  as  they  have  been  called, 
vermicular  contractions.  The  subcutaneous  contraction  of  muscular  fila- 
ments suggests  the  appearance  of  worms  crawling  beneath  the  skin,  and 
there  is  sometimes  a  species  of  muscular  shivering.  These  fibrillary 
contractions  may  be  excited  by  sharply  striking  the  muscles  with  a  ruler 
or  the  hand,  and  they  sometimes  follow  the  passage  of  the  galvanic  cur- 
rent through  the  nerve-trunk.  As  I  have  said,  the  hand  may  be  affected 
first,  and  there  may  be  extensive  wasting  here  before  other  parts  are 
attacked.  The  muscles  of  the  palm  of  the  hands,  when  atrophied,  give  to 
that  member  a  most  unsightly  appearance.  The  bones  stand  out  in  strong 
relief,  and  the  thenar  and  hypotlienar  eminences  are  flattened,  and  the 
flexor  tendons  are  prominent,  and  increase  the  deformity.  With  this 
there  is  contraction  of  the  flexors,  and  the  hand  resembles  more  the  claw 

Fig.  36. 


Main  en  Griffe."    (Roberts.) 


(Fig.  30)  of  an  animal  than  anything  else,  so  that  it  has  been  called  "le 
main  en  griffe."  The  back  of  the  hand  also  presents  a  most  skeleton-like 
aspect,  the  extensors,  the  interossei  muscles,  and  sometimes  the  adductive 
of  the  thumb  having  l>een  reduced  in  size.  The  forearm  and  arm  are 
next  to  follow,  and  rapidly  lose  their  normal  conformation.  The  deltoid 
and  serrati  muscles  may  be  involved,  while  those  of  the  arm  proper  may 
occasionally  be  passed  over.  The  head  of  the  humerus  and  angle  of  the 
scapula  are  quite  distinct,  and  this  bone  may  be  drawn  out  of  place  by  the 
healthy  muscles,  this  being  the  rule  when  the  serratus  magnus  is  the  seat 
of  atrophy.  The  angle  cf  the  scapula  is  drawn  upwards  and  inwards,  and 
stands  out  from  the  trunk.  It  is  rare  to  find  symmetrical  atrophy,  and  in 
the  majority  of  cases  I  have  seen  there  has  been  a  great  difference  in  the 
invasion  of  muscles  on  the  two  sides.  The  right  upper  extremity  appears 
to  be  the  favorite  seat  of  the  atrophy,  while  the  lower  extremities  are 
quite  rarely  affected,  and  in  the  proportion  of  1  to  12  to  the  upper  ex- 
tremities. The  muscles  of  the  face  and  head  are  sometimes  the  seat  of 
atrophy,  but  this  is  unusual,  though  muscles  may  occasionally  be  so  ex- 
tremely wasted  that  there  is  no  appearance  of  intelligence  whatever.  The 
eyes,  of  course,  being  unaffected  are  the  only  agents  of  expression.  There 


PROGRESSIVE    MUSCULAR    ATROPHY.  257 

may  be  atrophy  of  the  tongue  and  buccal  muscles,  with  disturbances  of 
speech  and  drooling  of  saliva,  and  in  such  cases  death  usually  follows 
in  a  very  short  time.  Sometimes  the  muscles  of  the  neck  do  not  escape 
the  extension  of  the  disease,  and  the  chin  falls  forwards  and  downwards. 
The  last  muscles  involved  are  generally  those  concerned  in  respiration ; 
and  not  only  are  the  intercostals  the  subjects  of  such  a  change,  but  the 
diaphragm  is  finally  paralyzed,  so  that  the  action  of  the  lungs  is  interfered 
with,  and  ultimately  the  patient  is  literally  asphyxiated.  Subsequent  to 
atrophy,  a  loss  of  power  takes  place.  The  affected  muscles  preserve  for  a 
long  time  their  electro-contractility  ;  but  this  is  finally  lost  as  they  decrease 
in  size,  and  loss  of  power  increases  till  finally  the  patient  becomes  helpless. 
Tactile  sensibility  is,  however,  rarely  blunted.  One  of  the  earliest  symp- 
toms of  progressive  muscular  atrophy  is  the  presence  of  dull  pains  in  the 
affected  limbs,  and  this  has  led  very  frequently  to  a  mistake  in  diagnosis, 
the  condition  being  often  considered  rheumatic.  In  one  case  sent  to  me 
by  Dr.  E.  G.  Loring,  I  found  that  the  atrophied  muscles  were  the  deltoid, 
serratus  magnus,  and  biceps,  but  none  of  the  lower  muscles  of  the  forearm 
were  attacked.  The  man  had  consulted  another  physician,  who  considered 
the  case  one  of  chronic  rheumatism,  and  prescribed  liniments  and  alkalies. 
The  patient  was  an  upholsterer,  and  had  been  obliged  to  use  his  right  arm 
to  a  great  extent,  especially  in  hammering  on  cornices,  and  putting  up 
decorations  which  were  above  his  head.  He  had  had  violent  pain  in  the 
shoulder  for  some  months,  and  subsequently  the  atrophy  began  in  the  del- 
toids. When  I  saw  him  the  head  of  the  humerus  was  prominent,  and 
there  were  fibrillary  contractions  in  some  of  the  muscles  of  the  back.  The 
progress  of  the  disease  is  marked  by  the  occurrence  of  well-marked  inter- 
missions, and  a  year  or  two  may  often  pass  without  any  extension,  while 
at  the  end  of  that  time  a  fresh  start  is  taken,  and  two  or  more  of  these  sta- 
tionary periods  are  not  uncommon  in  the  course  of  the  malady.  The 
ordinary  tendency  of  the  affection  is  however  progressive;  and  although, 
as  I  have  said,  the  disease  may  pursue  the  most  eccentric  course,  attack- 
ing groups  of  muscles  here  and  there,  it  will  involve  ultimately  a  very 
great  number,  and  finally  those  supplied  by  the  lower  cranial  nerves,  unless 
it  be  checked  by  proper  treatment. 

I  may  illustrate  the  symptomatology  of  progressive  muscular  atrophy  by 
a  case  which  ran  a  somewhat  irregular  course  by  attacking  the  muscles  of 
the  lower  extremities  : — 

J.  F.  H.,  31  years  old;  U.  S. ;  engineer.  Twenty-one  months  ago  the 
patient,  after  exposure,  developed  what  he  says  was  articular  rheumatism, 
which  chiefly  affected  the  legs.  On  recovery  he  noticed  that  the  right  leg 
"  began  to  grow  smaller  at  the  calf,"  and  that  afterwards  his  left  thigh 
became  smaller.  His  pains  continued  at  intervals,  and  were  increased  by 
damp  weather. 

Present  Condition The  muscles  of  the  anterior  part  of  legs  and  thighs 

are  much  wasted,  the  adductors  of  thighs  and  the  recti  femoris  on  both 
sides  being  notably  so.  The  knees  seem  very  large,  and  the  condyles  of 
the  femur  are  felt  to  be  superficial  and  covered  tightly  by  the  skin.  There 
IT 


258 


DISEASES    OF    THE    SPINAL    CORD. 


is  no  loss  of  sensation,  and  electric  irritability  appears  to  be  very  generally 
preserved,  except  in  the  recti  femoris.  The  glutei  muscles  have  sufti-n-.l 
to  some  extent  on  both  sides.  He  has  sevei'e  pain  at  night,  which  runs 
down  the  legs,  and  "  seems  to  be  deep."  There  is  impaired  motor  power, 
and  he  finds  that  walking  is  difficult.  He  does  not  experience  any  urinary 
trouble,  and  his  bowels  are  not  constipated.  There  is  no  loss  of  coordi- 
nating power,  no  constricting  band,  no  history  of  any  kind  of  acute  mye- 
litis. The  muscles  on  the  outer  side  of  the  thigh  are  the  seat  of  fibrillary 
contractions,  which  occur  sometimes  when  he  makes  a  voluntary  effort. 
There  was  at  this  time  no  atrophy  of  any  of  the  muscles  of  the  upper 
extremities,  but  when  I  saw  him  some  months  subsequently  there  was 
commencing  atrophy  of  the  muscles  of  the  right  hand.  In  the  paralyzed 

Fig.  37. 


Atrophy  of  Left  Shoulder. 

muscles  the  temperature  is  much  lowered,  and  this  is  a  constant  feature  ot 
the  disease.  Jaccoud1  and  others  have  called  attention  to  a  temperature 

lhange,  which  they  call  "  refroidissement  variable,"  in  which  there  are 
times  when  the  temperature  may  fall  several  degrees,  and  this  eeems  to  be 
the  result  of  a  paroxysmal  ischemia  of  the  tissues.  The  papillary  condition 

s  an  interesting  feature  of  the  disease,  the  dilators  sometimes  being  para- 
lyzed, so  that  the  pupils  are  widely  or  unequally  dilated. 

Causes — These  may  be  enumerated  as  heredity,  which  is  found  to 

iter  conspicuously  into  the   etiology  of  progressive   muscular  atrophy, 

exposure,  the  over-use  of  particular  groups  of  muscles,  injury  of  the  spi- 

d  cord,  and  sometimes  syphilis  and  the  zymotic  diseases.     As  to  the 

litary  influence  which  favors  its  development  Friedrich*  reports  several 


1  Op.  cit.,  p.  326. 


8  Ueber  Muskelatrophie,  etc.     Berlin,  1873. 


PROGRESSIVE  MUSCULAR  ATROPHY.  259 

cases,  and  Hammond1  others,  which  go  to  show  that  this  disease  more  than 
all  others  commonly  appears  in  several  generations  of  the  same  family.  I 
have  seen  one  case  where  it  could  be  traced  for  three  generations  back, 
and  in  another,  which  I  will  presently  detail,  there  were  uncles  and  aunts 
affected.  Eichert,2  in  a  very  valuable  article,  gives  the  family  history  of 
one  case.  In  a  genealogical  table  he  traced  the  disease  back  six  genera- 
tions, and  representatives  of  these  generations  are  still  living.  Seven 
cases  are  related  by  him.  In  two  of  the  cases  the  parents  have  escaped, 
while  the  children  have  suffered.  It  is  unnecessary  to  pursue  this  matter 
further,  but  I  am  firmly  convinced  that  there  is  no  other  disease,  except 
perhaps  it  may  be  phthisis  pulmonalis,  which  is  transmitted  so  frequently 
as  this  terrible  malady.  Exposure  to  damp,  neglect  to  change  wet  cloth- 
ing, and  like  imprudences,  are  exciting  causes  in  many  cases.  Neuralgic 
pains  are  very  prominent  in  such  cases,  and  the  onset  of  the  disease  is 
rather  precipitate.  Mechanics  of  all  kinds,  who  are  in  the  habit  of  using 
some  muscles  much  more  than  others,  are  frequently  the  victims  of  the 
disease,  and  the  muscles  which  have  been  over-used  are  affected  before  the 
others.  The  case  of  a  ballet-dancer  is  reported  by  Hammond  in  which 
the  sural  muscles  were  affected,  and  I  have  seen  the  same  limited  atrophy 
in  a  cigar-maker  and  in  a  compositor,  who  used  certain  groups  of  muscles 
almost  constantly.  Roberts  has  dwelt  upon  the  connection  between  injury 
of  the  spinal  cord  and  the  disease  under  consideration ;  and  Valentiner,3 
Bergmann,*  and  Thudicum  have  all  called  attention  to  the  appearance  of 
the  disease  some  time  after  the  receipt  of  an  injury.  Roberts  reports  a 
case  in  which  atrophy  of  the  ball  of  the  right  thumb,  and  subsequent  com- 
plication of  the  respiratory  muscles,  and  death  followed  a  slight  injury 
received  six  months  before.  The  other  cases  are  none  the  less  interesting, 
and  go  to  prove  the  importance  of  recognizing  such  causes.  As  to  age  and 
sex  it  has  been  found  that  progressive  muscular  atrophy  is  not  confined  to 
any  period  of  life,  but  the  bulk  of  cases  occur  after  puberty.  Of  88  cases 
reported  by  Roberts,  1  was  only  2  years  old  and  another  69.  Of  the 
28  cases  I  have  seen,  the  atrophy  began  in  2  between  the  5th  and  10th 
years ;  in  5  between  the  10th  and  loth ;  in  18  between  the  20th  and  the 
30th;  and  in  3  after  the  30th.  Of  these,  23  were  men,  and  but  5 
women.  This  seems  to  be  the  rule,  and  Roberts  states  that  six  men  are 
affected  to  every  woman,  and  he  considers  this  due  to  the  exposure  and 
external  violence  to  which  males  are  subjected. 

Morbid  Anatomy  and  Pathology — The  disputed  point  in  regard 
to  the  pathology  seems  to  be  whether  it  is  a  primary  peripheral  condition, 
or  whether  it  is  a  central  affection  in  which  the  trophic  cells  are  affected. 
The  advocates  of  the  first  theory  call  attention  to  the  fact  that  muscular 
atrophy  occurs  independent  of  any  loss  of  the  muscular  function,  and 
believe  it  to  be  purely  a  local  degeneration.  The  authorities  I  have  spoken 

1  Op.  cit.,  p.  526.  2  Berliner  Klin.  Wochenschrift,  Oct.  20,  1874. 

2  Frag.  Yiert.,  1855.  4  Petersburg  Met! .  Zeitsch.,  1864. 


260  DISEASES    OF    THE    SPINAL    CORD. 

of,  in  alluding  to  the  early  history  of  the  disease,  all  believed  in  this  intra- 
muscular origin,  but  lately  there  have  been  so  many  proofs  of  its  central 
origin  brought  forward,  that  the  former  theory  has  been  abandoned.  This 
difference  of  opinion  seems  to  exist  in  regard  to  the  form  of  central  lesion. 
The  majority  of  observers  are  agreed  that  there  is  an  affection  of  tin- 
anterior  horns ;  and  that  the  change  is  one  that  affects  the  trophic  cells 
of  Duchenne  and  Westphall,  and  the  fibres  which  connect  with  sym- 
pathetic ganglia. 

To  Loekhart  Clarke,1  who  has  so  often  decided  questions  regarding  the 
pathology  of  nervous  disease,  belongs  the  credit  of  having  discovered  the 
central  origin  of  this  disease.  He  has  found  atrophy  of  the  anterior  gray 
horns,  and  since  his  original  observations  many  other  observers  have 
come  forward  to  endorse  his  views.  Von  Recklinghausen  and  Dumenil3 
disagree,  however,  with  this  view,  and  the  microscopical  examination 
made  by  the  former  was  unattended  with  any  discovery  of  morbid  ap- 
pearances. 

Jaccoud  has  collected  six  cases  in  which  fatty  degeneration  of  the  sym- 
pathetic had  taken  place,  and  one  of  them  was  observed  by  Jaccoud 
himself.  Not  only  was  there  fibre-fatty  degeneration  of  the  sympathetic 
nerve,  but  there  was  atrophy  of  the  anterior  roots.  The  view  held 
by  Jaccoud  is  that  the  trophic  filaments  of  the  sympathetic  which  pre- 
side over  nutrition  do  not  perform  their  duty,  and  that  the  affection  of 
a  mixed  nerve,  which  contains  motor,  sensor,  and  trophic  filaments,  at  a 
point  where  they  are  intimately  mixed,  must  result  in  a  perversion  of  all 
their  functions,  but  if  the  separate  filaments  be  attacked  at  a  point  before 
they  become  blended,  there  may  be  independent  loss  of  function  of  either 
one.' 

Charcot*  and  Gombault  have  described  the  following  interesting  post- 
mortem appearances  witnessed  in  a  recent  case : — 

"  No  change  in  hemisphere,  cerebellum,  pons,  or  medulla  oblongata  in 
these  nerves.  The  gray  substance  of  the  cervical  and  dorsal  medulla 
spinalis  was  greatly  altered  from  the  lower  portion  of  the  cervical  enlarge- 
ment down,  gradually  decreasing  downwards  and  outwards.  The  nerve- 
cells  and  nerve-fibres  of  the  anterior  gray  cornua  had  disappeared  ;  the 
capillary  vessels  were  greatly  developed;  the  parietes  of  the  smaller  and 

1  Brit,  and  For.  Mcd.-Chir.  Review,  vol.  xxx.,  1862. 

2  (Jaz.  Hclxlom.,  1867. 

8  The  localization  of  well-defined  lesions  in  this  disease  is  sometimes  made  be- 
fort:  death  and  verified  afterwards.  Prevost  and  Cotard  (Archives  de  Physiol., 
Sept.  1 874)  present  such  a  ease.  There  was  atrophy  of  the  right  thenar  eminence, 
with  atrophy  of  the  right  anterior  root  of  the  eighth  pair  of  cervical  nerves,  slightly 
marked  atrophy  of  the  right  anterior  root  of  the  seventh  cervical  nerves,  and 
atrophy  of  the  gray  matter  of  the  anterior  horn  at  this  level  of  about  an  inch  in 
extent. 

4  Archiv.  dc  Physiol.,  1875,  No.  5,  abst.  Phil.  Med.  Times. 


PROGRESSIVE    MUSCULAR    ATROPHY.  261 

larger  vessels  were  thickened.  The  lumbar  portion  of  the  cord  and  the 
lateral  columns  were  normal.  In  the  cervical  and  dorsal  region,  the  por- 
tions of  the  cord  near  the  merging  external  roots  were  sclerosed ;  the 
change  being  proportionate  to  the  intensity  of  that  which  had  taken  place 
in  the  gray  cornua.  The  few  ganglion-cells  present  were  very  much 
diminished  in  size,  without  processes,  more  rich  in  pigment  than  normal, 
but  still  containing  nuclei  and  nucleoli.  The  anterior  roots  of  the 
cervical  region  were  atrophic  ;  empty  sheaths,  frequently  containing  large 
nuclei,  appeared  in  place  of  the  normal  fibrillar  contents.  The  posterior 
roots  seemed  normal. 

"As  to  the  peripheral  nerves,  one  phrenic  and  several  intercostal  nerves 
were  examined ;  more  than  two-thirds  of  the  nerve-tubules  (in  hardened 
sections)  were  wanting,  by  a  process  similar,  as  it  would  appear,  to  that 
induced  by  an  external  wound.  The  muscles  about  the  shoulder  and  the 
upper  extremities  were  for  the  most  part  atrophic  ;  there  seemed  to  be  a 
peculiar  atrophy  of  the  primitive  fasciculi,  without  any  marked  alteration 
in  the  fibrils,  and  without  any  excessive  development  of  the  interfibrillar 
fatty  tissue." 

Lockhart  Clarke1  has  discovered  marked  changes  in  the  gray  matter. 
There  was  a  granular  deposit  about  the  vessels,  and  corpora  amylacea 
about  the  central  canal.  Lesions  of  the  anterior  nerve-roots  were  found, 
and  in  the  cervical  region  there  seemed  to  be  more  distinct  appearances 
than  at  any  other  point,  where  it  will  be  remembered  there  may  be  found 
sympathetic  as  well  as  motor  and  sensor  fibres. 

The  muscles  present  distinct  evidences  of  fatty  degeneration  and  fatty 
substitution.  They  appear  to  the  naked  eye  as  wasted  bands  which  con- 
tain lines  of  fat.  The  appearance  of  healthy  muscles  of  good  contour  in 
juxtaposition  with  others  which  have  undergone  atrophy  is  very  peculiar, 
and  it  is  difficult  to  realize  that  the  disease  can  involve  such  isolated 
tracts.  The  muscles  of  the  lower  extremities  may  have  undergone  general 
fatty  degeneration.  A  specimen  prepared  by  my  friend  Dr.  Weiss,  of  the 
Medical  Department  of  the  N.  Y.  University,  shows  very  beautifully  this 
condition  of  affairs.  Fatty  substitution  has  gone  on  to  such  an  extent 
that  there  is  no  appearance  of  muscular  fibre  to  be  seen,  but  every  muscle 
exists  as  a  distinct  band  of  adipose  tissue.  Atrophied  muscles  have  been 
examined  by  Meryon,2  Galliet,3  and  others,  and  their  descriptions  of  ap- 
pearances agree  very  closely.  The  muscular  structure  suffers  a  complete 
change,  the  striae  disappearing  and  the  sarcolemma  undergoing  a  granular 
change.  Fox4  divides  the  secondary  changes  into  the  fatty  degeneration 
which  takes  place  inside  of  the  sarcolemma,  and  as  an  interstitial  deposit. 
These  he  calls  the  parenchymatous  and  the  interstitial.  Sometimes,  as 
observed  by  Robin,  the  atrophy  may  take  place  as  a  fibrous  degeneration, 
or  species  of  muscular  sclerosis.  Some  muscles  appear  as  fibrous  cords  of 
a  white  color,  while  others  may  be  found  which  have  undergone  the  fatty 
degeneration  just  described. 

1  Mod.  Chir.  Trans.,  1851,  1856.  2  Ibid.,  1866. 

3  Archiv.  Gen.,  vol.  i.,  5me  s6rie,  1853,  p.  584.  4  Op.  cit.,  p.  266,  etseq. 


262  DISEASES    OF    THE    SPINAL    CORD. 

An  instructive  case  in  which  very  striking  appearances  were  presented 
was  observed  by  my  friend,  Dr.  Janeway,  whose  observations  are  recorded 
below : — 

M.  G.,  aged  02  years,  widow  ;  admitted  to  hospital  December  16th, 
1873.  Right  hand :  the  muscles  of  ball  of  thumb  are  very  much  atro- 
phied, and  she  is  unable  to  move  it ;  there  is  also  slight  rigidity  of  the 
joints  of  the  thumb. 

Dorsal  interossei  are  very  much  wasted  ;  there  is  slight  power  of  flexion 
and  extension  of  fingers,  especially  little  fingers,  and  there  is  also  a  slight 
movement  at  the  wrist. 

Sensibility  good,  except  in  index  finger,  and  here  it  is  decidedly  dimin- 
ished. She  can  raise  her  arm  to  her  head  and  place  it  in  any  position. 
Hands  seem  cold. 

Left  hand  is  not  so  much  affected ;  the  muscles  of  ball  of  thumb  are 
partiallv  wasted.  The  abductor  opponens  and  outer  head  of  flexor  brc\  is 
are  almost  gone ;  the  inner  head  of  flexor  brevis  and  abductor  partially, 
and  capable  of  acting  to  a  slight  extent.  Has  slight  power  of  ;il>-  and  ad- 
duction of  fingers,  especially  the  little  finger,  most  on  the  ulnar  side,  and 
decreasing  toward  the  radial ;  has  slight  power  of  extension  over  fingers, 
none  over  thumb,  but  flexion  power  is  more  marked.  Has  no  power  of 
extension,  but  considerable  of  flexion  at  the  wrist. 

Dynamometer  L.  II.  28.     Sensibility  normal ;  hands  cold.     The  mus 
cles  that  are  capable  of  acting  respond  to  the  induced  current  very  well. 

July  9.   Complains  of  dizziness  and  nausea. 

17M.  Dizziness  still.  Her  hands  are  in  same  condition.  She  expe- 
riences some  difficulty  in  walking,  and  moves  with  her  body  "  sloping 
over."  She  cannot  use  her  hands,  and  when  she  attempts  to  do  any- 
thing, they  drop,  and  she  cannot  raise  them.  The  muscles  that  remain 
unaffected  respond  well  to  electricity.  She  still  vomits  at  times  after 
eating. 

August  3.  Is  quite  weak  ;  has  chilly  sensations. 

.4th.  Had  a  severe  fever  last  night;  temp.  104°;  passed  feces  in  bed, 
and  did  not  know  it ;  to-day  temp,  is  almost  normal ;  is  quite  apathetic. 

itth.  Has  chilly  sensations;  complains  of  no  pain  ;  arms  and  jaws  trem- 
ble ;  temp.  102°. 

2  P.  M.  Temp.  102°. 

ftth.  She  is  very  much  worse  ;  mucous  rales  heard  all  over  chest ;  respi- 
ration accelerated  ;  temp,  high  ;  pulse  very  feeble  ;  pupils  normal ;  bowels 
moved  once  to-day  ;  swallows  with  great  difficulty. 

2  P.  M.  She  sank  gradually,  and  died  at  12.45  P.  M. 

Post-mortem,  held  tirrnty-seven  hours  after  death Rigor  mortis  mode- 

ratelv  well  marked.  Nearly  all  the  muscles  of  the  hands  are  atrophied, 
especially  the  dorsal  interossei  and  the  propria  muscles  of  the  thumb ;  the 
change  is  nearly  symmetrical  in  both  hands.  The  forearms  are  extremely 
wasted,  !>oth  on  the  flexor  and  extensor  surfaces.  There  is  no  marked 
wasting  in  the  arms,  the  shoulders  are  well  rounded  ;  both  pectoral  regions 
appear  waited  ;  there  is  no  marked  wasting  in  the  lower  extremities,  un- 
less it  be  in  the  adductor  region  of  both  thighs.  Incisions  made  into  the 
pectoral  muscles  show  well-colored  fibres  also  in  the  deltoid,  biceps,  and 
triceps. 

The  extensors  of  the  forearms  are  of  whitish-yellow  color,  being  nearly 
as  pale  as  the  skin. 


PROGRESSIVE    MUSCULAR    ATROPHY.  263 

The  flexors  of  right  hand  are  very  much  wasted,  but  not  so  much  as 
the  extensors.  The  flexors  of  the  left  side  are  small,  but  seem  in  good 
condition. 

The  muscles  of  the  right  thenar  eminence  show  extreme  degeneration. 
In  left  thenar  eminence  the  inner  head  of  flexor  brevis  and  adductor  are 
red  and  large  ;  the  external  is  white,  as  on  the  other  side.  The  adductors 
of  thighs  are  small,  but  well-colored. 

The  quadriceps  extensor  femoris  is  of  good  color. 

The  anterior  tibial  muscles  are  of  good  color. 

Heart :  Valves  are  normal,  muscular  substance  soft  and  yellowish-gray. 
The  diaphragm  is  not  atrophied. 

Brain  :  Convolutions  and  corpora  striata  appear  normal.  There  is  some 
atheroma  of  the  carotid  and  basilar  arteries. 

The  substance  of  the  cord  and  brain  is  quite  soft.  The  viscera  are 
normal,  except  the  kidneys,  and  these  are  granular ;  their  pyramids  are 
small,  and  they  contain  small  cysts. 

Diagnosis. — Progressive  muscular  atrophy  may  be  mistaken  for  seve- 
ral conditions  of  a  paralytic  nature,  among  these  lead  paralysis,  antero- 
lateral  sclerosis,  and  partial  paralysis  from  traumatism. 

For  an  illustration  of  the  first  of  these  I  do  not  think  I  can  do  better 
than  mention  a  case  in  which  there  appeared  to  be  lead  paralysis,  but 
which  subsequently  turned  out  to  be  progressive  muscular  atrophy. 

Several  months  ago  Mr.  N.,  a  Cuban  gentleman,  came  to  me  with  a 
letter  from  his  medical  adviser,  Dr.  Findlay,  of  Havana.  The  doctor's 
history  of  the  patient  is  as  follows :  "  Mr.  N.,  about  eighteen  months  ago, 
began  to  experience  a  tremor  in  the  fingers  and  wrist  of  the  right  hand, 
together  with  muscular  debility,  which  caused  some  inconvenience  in  writ- 
ing, and  in  carrying  food  to  his  mouth,  as  well  as  in  other  movements  of  the 
hand.  Having  on  a  single  occasion  submitted  to  local  faradization  of  the 
arm  (some  ten  months  ago),  the  tremor  was  much  subdued,  and,  as  was 
thought,  the  fingers  and  wrist  were  strengthened.  It  was  not,  however, 
until  four  months  ago  that  the  patient  returned  to  put  himself  under  a 
regular  course  of  treatment. 

"  Condition  of  the  patient  in  July,  1876 — General  health  good;  no  signs 
of  cachexia  ;  no  antecedents  of  specific  taint ;  no  lead  poisoning.  Suffered 
on  two  or  three  occasions,  at  some  years'  interval,  rheumatic  pains  and 
neuralgia  in  the  arm  and  shoulder  of  the  left  side,  but  never  in  the  right 
side,  which  is  the  one  now  affected.  The  outer  appearance  of  the  right 
arm  showed  but  little  muscular  atrophy ;  the  tremor  was  inconsiderable  ; 
the  patient  could  close  the  hand  tightly,  but  not  well  grasp  larger  objects, 
such  as  a  tumbler,  owing  to  incapacity  to  maintain  the  first  phalanx  of  the 
third,  fourth,  and  fifth  fingers  extended.  The  wrist  was  inclined  to  drop 
forwards  (in  flexion)  and  outwards. 

"  On  inspection  it  was  found  that  the  common  extensor  of  the  fingers 
was  considerably  weakened,  most  so  in  the  portion  attached  to  the  ring- 
finger,  the  weakness  being  manifested  both  to  voluntary  and  to  electrical 
contractility.  The  same  condition  existed  also,  though  a  little  less,  in  the 
extensor  of  the  little  finger,  and  in  the  radial  extensors.  The  contractility 
was  not  totally  absent,  but  would  vary  in  degree  without  apparent  cause. 
The  disease  continued  to  progress  (notwithstanding  treatment),  the  por- 


264  DISEASES    OF    THE    SPINAL    CORD. 

tions  of  the  common  extensors  losing  all  excitability  to  my  small  Gaiffe's 
battery,  and  the  extensors  of  the  thumb  being  also  implicated. 

"  The  left  arm  was  now  examined,  and  although  the  patient  did  not 
notice  any  weakness  in  the  hand,  some  deficiency  of  electric  contractility 
was  observed  in  the  common  extensor,  especially  in  the  extensor  of  the 
ring-linger.  The  constant  current  was  now  used  for  six  weeks  without 
much  benefit.  The  extensor  carpi  ulnaris  is  now  becoming  also  affect  rd. 
The  patient,  however,  finds  that  he  can  write  and  perform  various  acts 
with  the  right  hand  better  than  before.  Within  the  last  week  he  com- 
plains of  some  pain  along  the  back  of  the  left  forearm  when  he  has  been 
holding  an  object  in  the  air,  and  feels  an  inclination  to  relax  his  grasp." 

The  Doctor  also  gave  a  history  of  hereditary  trouble,  which  was  probably 
in  one  case  (the  patient's  uncle)  progressive  muscular  atrophy. 

I  can-fully  examined  the  patient,  and  found  that  the  right  arm  was  that 
most  affected. 

Motor  power The  power  of  extension  of  the  muscles  of  the  right  fore- 
arm was  lost  completely,  and  on  the  left  side  the  power  of  extension  of  the 
two  middle  fingers  was  to  some  degree  impaired.  Flexion  was  perfect. 

Atrophy. — The  following  muscles  were  more  or  less  affected  and  reduced 
in  size.  Hight  forearm:  Extensor  communis  digitorum;  extensor  minimi 
digiti ;  extensor  carpi  radialis ;  extensor  longus  pollicis ;  extensor  carpi 
ulnaris  ;  extensor  communis  of  the  left. 

Sensation — Slightly  impaired  on  the  right  side.  The  teeth  of  the 
a?sthesiometer  were  separated  by  a  space  of  about  ten  centimetres  before 
two  points  could  be -appreciated.  This  loss  was  not  so  great  on  the  under 
surface  of  the  forearm.  There  was  no  history  of  recent  pain  either  con- 
stant or  neuralgic,  nor  were  there  any  dyszesthetic  sensations. 

No  fibrillary  contractions  were  observed.  There  was  a  slight  tremor 
in  the  right  hand  when  voluntary  movements  were  made.  Electric  con- 
tractility to  a  very  slight  degree  was  observed  in  the  extensor  communis 
digitorum  when  a  strong  faradic  current  was  applied.  The  galvanic  cur- 
rent also  seemed  to  have  some  influence  upon  the  weakened  muscles.  The 
fingers  were  covered  by  small  flakes  of  skin,  and  the  nails  were  crenated, 
irregular,  and  evidently  badly  nourished.  This  trophic  defect  disappeared 
under  the  use  of  the  galvanic  current. 

Diagnosis — In  the  order  I  name  them  I  proceeded  to  dispose  of  lead 
paresis,  amyotrophic  sclerosis,  cerebral  paralysis,  traumatic  paralysis,  and 
progressive  muscular  atrophy. 

That  it  might  be  lead  paresis  seemed  reasonable  at  first,  because  of  the 
loss  of  electric  contractility,  the  seat  of  the  paralysis,  etc. ;  but  when  I  bore 
in  mind  that  the  trouble  was  one-sided  at  first,  that  there  was  a  subsequent 
invasion  of  the  muscles  of  the  other  arm,  that  sensibility  was  also  impaired, 
and  that  the  patient  used  neither  hair-dye  nor  drank  impure  water,  nor 
was  exposed  to  the  dangers  of  lead  poisoning  of  any  kind,  I  was  forced  to 
abandon  this  idea.  A  species  of  spastic  contraction  drew  down  the  fin- 
gers of  UN?  right  hand,  and  there  was  some  cumulative  tremor,  such  as 
characterizes  sclerosis  (expressed  by  a  gradually  increased  tremor,  aggra- 
vated by  will  control,  and  terminating  in  a  species  of  spasm).  This  at 
first  led  me  to  suppose  that  there  might  be  some  degeneration  of  the  lateral 
columns,  but  as  the  tremor  disappeared  and  there  were  no  other  symptoms 
of  such  degeneration,  and  especially  as  there  was  gradual  atrophy  and  mus- 
cular paralysis,  I  dismissed  this  possibility.  The  loss  of  electric  contrac- 


PROGRESSIVE    MUSCULAR    ATROPHY.  2G5 

tility,  and  the  limited  field  of  the  paralysis,  excluded  cerebral  paralysis ; 
and  the  fact  that  the  patient  had  never  received  an  injury,  and  that  the 
affection  was  beginning  to  affect  the  opposite  group,  negatived  the  theory 
of  traumatic  paralysis.  All  that  was  left  was  the  diagnosis  of  progressive 
muscular  atrophy;  and  the  subsequent  appearance  of  fibrillary  contractions 
made  me  quite  sure  of  my  decision.  The  slow  progress  of  the  trouble  and 
its  site  were,  however,  doubtful  points.  The  individual  had  not  exercised 
any  particular  member,  and  as  he  was  a  man  of  leisure,  there  was  no  trade 
or  occupation  in  which  constant  use  of  the  hands  or  excessive  labor  was 
required  that  could  account  for  its  origin.  The  hands  preserved  their 
contour  ;  there  was  no  atrophy  ;  no  prominent  thenar  eminences  ;  nothing 
suggestive  of  the  main  en  ffriffe.  None  of  the  muscles  of  the  back  were 
affected,  and  the  deltoids  were  of  good  volume  and  power.  The  fact  that 
others  in  his  family  had  suffered,  that  the  disease  began  on  one  side  and 
extended  to  the  other,  that  fibrillary  contractions  were  present,  that  sub- 
sequently I  was  enabled  to  get  slight,  and  afterwards  stronger  contractions 
of  the  paralyzed  and  atrophied  muscles,  determined  me  in  my  diagnosis  of 
this  anomalous  case.  I  call  it  anomalous,  because  I  have  been  taught,  and 
my  own  experience  convinces  me,  that  this  is  a  very  rare  seat  of  progres- 
sive muscular  atrophy.  Protean  as  is  the  malady,  I  have  not  seen  para- 
lysis of  the  extensors,  as  a  primary  symptom,  in  any  one  of  the  twenty- 
eight  cases  of  the  affection  I  have  met  with  from  time  to  time. 

In  lead  paresis  the  invasion  is  rapid,  the  paralysis  the  same,  and  the 
atrophy  is  secondary,  which  is  not  the  case  in  the  wasting  palsy.  There 
is  sometimes  the  lead  line  or  lead  colic,  and  electric  contractility  is  im- 
paired from  the  first.  From  traumatic  paralysis  it  can  be  diagnosed  by 
the  irregularity  in  situation  of  the  muscles  atrophied.  In  traumatic 
paralysis  we  may  look  for  ati-ophy  of  groups  of  muscles  which  are  sup- 
ported by  a  common  trunk,  as  well  as  loss  of  electric  contractility  and 
secondary  atrophy. 

Prognosis Occasionally  the  disease  may  be  arrested  or  cured  en- 
tirely, and  this  fact  seems  almost  incredible  when  we  bear  in  mind  its 
organic  character.  I  have  succeeded  in  arresting  the  disease  in  ten  cases, 
and  think  that,  when  there  is  the  least  muscular  response  to  electricity, 
there  is  still  a  chance  for  improvement,  if  not  complete  relief.  This 
is,  of  course,  in  proportion  to  the  extent  of  invasion.  If  the  atrophy  be 
confined  to  the  muscles  of  one  forearm,  there  need  be  no  reason  to  give  a 
bad  prognosis.  The  majority  of  cases,  however,  go  on  to  an  unfavorable 
termination,  and  perhaps  one  reason  is,  that  patients  delay  so  long  to  seek 
medical  advice,  considering  their  disease  to  be  rheumatism,  and  amenable 
to  domestic  treatment. 

Roberts'  thinks  that  the  prognosis  is  bad  when  hereditary  predisposition 
can  be  traced,  or  when  the  upper  and  lower  extremities  are  both  impli- 
cated. 

Treatment. — I  know  of  no  other  remedies  than  those  which  are  local 
(except  when  a  syphilitic  taint  is  suspected).  Electricity  is  one  of  these; 

1   Art.  Wasting  Palsy,  Reynolds's  System  of  Medicine,  vol.  ii.  p.  349. 


266  DISEASES    OF    THE    SPINAL    CORD. 

muscular  rest  is  the  second  when  the  affection  has  followed  overuse  of 
certain  muscles. 

The  galvanic  current  from  not  less  than  twenty  cells  should  be  used, 
one  electrode  being  placed  over  the  nucha,  and  the  other  in  the  supra- 
clavicular  space.  Seances  of  ten  minutes  every  day  cannot  fail  to  do 
good.  In  addition  to  this,  the  faradic  current  should  be  employed  for  the 
muscles  themselves.  I  have  tested  the  plan  of  Duchenne,  who  recom- 
mends painful  and  ]>owerful  currents,  and  have  not  found  it  successful.  I 
prefer  rather  to  make  each  muscle  contract  several  times,  and  then  allow 
it  to  rest,  and  repeat  the  operation  some  minutes  afterwards.  Violent 
electri/ation,  I  am  convinced,  fatigues  these  crippled  muscles,  and  does 
more  harm  than  good.  Vivian-Poore  and  Fagge1  have  had  wonderful 
success  with  this  agent,  and  have  cured  a  number  of  apparently  hopeless 
cases.  I  have  been  induced  to  try  the  "  rubber  muscle,"  as  arranged  for 
h-ad  paresis.  This  forms  an  admirable  means  for  support  of  the  hands, 
should  the  extensors  be  affected,  as  was  the  case  in  the  history  I  have  just 
related.  In  every  case  it  is  well  to  insure  perfect  rest,  if  possible,  for  all 
affected  muscles.  If  the  muscles  of  the  shoulder  be  so  atrophied  as  to 
allow  the  arm  to  drop,  it  is  well  to  arrange  some  contrivance  to  sustain 
its  weight,  and  relieve  the  strain  upon  the  affected  organs.  Sulphur 
baths  and  mineral  waters  have  been  recommended,  and  in  some  hands 
have  been  successful. 


PARTIAL  FACIAL  ATROPHY. 

Synonyms — Trophic  neurosis  of  the  face  (Romberg)  ;  Laminar 
aphasia  (Lande)  ;  Progressive  facial  atrophy  (Hammond). 

The  disease  was  first  described  by  Romberg1  in  1837,  and  subsequently 
by  Lande,*  Samuels,4  Bergson,6  Eulenberg,6  Fremy,T  and  Moore,8  who 
have  all  reported  cases.  Eleven  example's  were  collected  by  Lande  alone, 
who  studied  the  disease  quite  faithfully.  The  only  American  case,  besides 
those  reported  by  Hammond9  and  Bannister,10  was  presented  at  a  meeting 
of  the  New  York  Society  of  Neurology,  December  20,  1875,  by  Dr.  Wil- 
liam II.  Draper,"  and  I  then  hud  the  opportunity  of  examining  her,  and 
subsequently  obtained  a  photograph,  a  copy  of  which  is  presented. 

1   London  Practitioner,  Dec.  1868. 

1  Klinisrhe  Wahremung  und  Beobachtungen,  Berlin,  1851. 

3  These  de  Paris,  1868. 

4  Dor  Tropischen  N erven,  Leipzig,  1860. 

*  DII  Prosopodymnorphia  sive  Nova  Atroph.  Fac.,  Berlin,  1873. 
6  Lehrlnieh  der  Funct.  N.  K.,  Berlin,  1871. 

Ktmle  critique  de  la  Troplionevrose  faciale,  Paris,  1872. 
8  Dublin  Quarterly  Journal,  1852. 

*  Op.  cit.,  p.  543,  ct  seif. 

10  Journal  of  Nervous  and  Mental  Diseases,  1877. 

"  Reported  in  Am.  Psychological  Journal,  Feb.  1876. 


PARTIAL    FACIAL    ATROPHY.  267 

The  patient,  who  was  a  stout,  hearty  Irish  girl,  aged  18,  and  without 
any  hereditary  predisposition,  presented  herself,  with  the  following  his- 
tory :  About  two  years  ago  the  muscles  under  the  body  of  the  lower  jaw 
of  the  left  side  began  to  diminish  in  size,  and  after  a  few  months  there 
was  gradual  extension  of  the  atrophy,  so  that  finally  a  district  bounded  by 
the  symphysis  of  the  lower  jaw,  angle  of  the  nose,  and  middle  of  the 

Fig.  38. 


Partial  Facial  Atrophy. 

upper  lip  in  front,  lower  edge  of  zygoma  above,  and  ramus  of  the  inferior 
maxillary  behind,  became  entirely  affected.  The  skin  is  bound  down  to 
the  periosteum  of  the  lower  jaw,  and  is  shiny,  tense,  and  white.  There 
never  has  been  pain  of  any  kind,  but  the  only  sensory  alteration  occurred 
in  the  beginning,  when  a  slight  itching  was  felt.  There  is  no  anaesthesia 
anywhere,  not  even  in  the  tongue,  one  side  of  which  is  markedly  atro- 
phied. In  the  beginning  there  were  occasional  cramp-like  pains  about  the 
insertion  of  the  masseter  muscles  on  the  left  side,  but  none  dn  the  other. 
There  was  slight  paresis  in  some  of  the  muscles  involved. 

In  twelve  Continental  cases  collected  by  Draper,  eight  of  whom  were 
women  and  four  men,  the  atrophy  appeared  in  one  at  three  years  of  age, 
and  in  another  at  twenty -two  years  of  age.  The  beginning  of  the  atrophy 
in  these  cases  was  not  always  the  same.  In  two  instances  it  began  by 
pallor ;  in  the  others  by  red  spots,  next  followed  by  loss  of  color ;  and 
finally  there  was  a  parchment-like  appearance  of  the  skin.  Sensibility 
was  not  lowered  in  any  instance,  but  in  two  there  was  itching,  as  in 
Draper's  case.  In  one  the  disease  was  preceded  by  spasms  of  the  mas- 
seter muscles  ;  in  six  the  tongue  was  atrophied  ;  in  one  the  tonsil ;  and  in 
the  rest  the  soft  palate.  In  two  cases  there  was  deafness.  In  no  case 
was  there  affection  of  the  secretion  of  saliva ;  but  in  one  there  was  dimin- 
ished pulsation  in  the  carotid  of  the  affected  side.  In  none  were  there 
indications  of  central  disease.  The  cutaneous  changes  alluded  to  are 
peculiar,  and  a  variety  of  trophic  alterations  may  attend  the  disease ; 


268  DISEASES    OF    THE    SPINAL    CORD. 

such,  for  instance,  as  falling  out  of  the  hair,  or  changes  in  color  and  the 
appearance  of  eczema.  The  atrophy  is  sometimes  quite  extensive,  involv- 
ing the  bones,  which,  in  some  cases,  have  been  measured  and  found  to  be 
greatly  reduced  in  size.  Electric  contractility  of  the  muscles  does  not 
appear  to  be  in  the  least  diminished.  The  temperature  of  the  affected 
side  is  generally  lowered,  but  there  is  no  diminution  of  sensibility.  The 
left  side  appears  to  be  the  more  common  seat  of  the  disease,  and  of  the 
twelve  cases  already  alluded  to,  but  one  was  of  the  right  half  of  the  face. 

Causes In  some  of  the  reported  cases  there  was  a  history  of  pre- 
vious intermittent  fever,  scarlatina,  and  scrofula,  and  in  one  case  there 
was  a  traumatism,  but  it  is  a  question  of  great  doubt  whether  these  were 
concerned  in  the  development  of  the  atrophic  condition.  It  seems,  how- 
ever, to  be  a  disease  which  is  more  common  between  the  tenth  and  the 
thirtieth  year. 

Pathology Undoubtedly  this  disorder  is  one  of  a  trophic  nature, 

and  of  central  origin.  The  absence  of  motorial  or  sensorial  disturbance 
makes  this  theory  very  plausible.  Hammond  considers  the  unilateral 
character  of  the  affection  a  strong  argument  against  the  theory  of  its  peri- 
pheral origin.  If  the  lesion  were  of  a  peripheral  character,  it  is  highly 
probable  that  both  sensation  and  motion  would  be  affected,  for  I  cannot 
conceive  a  diseased  condition  of  trophic  filaments  alone  when  they  are 
found  in  company  with  other  sensor  and  motor  filaments,  as  in  a  nerve- 
trunk  which  is  diseased.  This  hypothesis  seems  more  reasonable  when  it 
is  borne  in  mind  that  the  parts  atrophied  are  supplied  by  other  cranial 
nerves  than  the  seventh.  I  therefore  think  that  the  theory  of  degeneration 
of  the  trophic  cells  of  the  bulb  is  a  much  more  acceptable  one  than  that  held 
by  Bergson  and  others.  Kulenberg  considers  it  to  be  essentially  a  lesion 
of  the  fifth  pair,  in  which  opinion  he  is  sustained  by  Romberg,  Samuels, 
Charcot,  and  Vulpian.  Against  this  it  may  be  urged  that  lesions  of  the 
tit'tli  nerve  of  a  trophic  nature  are  generally  followed  by  corneal  changes, 
which,  as  far  as  I  can  learn,  have  never  been  witnessed  in  this  disorder. 

Diagnosis — Progressive  muscular  atrophy  and  facial  paralysis  seem 
to  be  the  only  diseases  with  which  that  under  discussion  may  be  con- 
founded. Against  the  first  it  may  be  said  that  there  are  never  the  pecu- 
liar cutaneous  changes  of  the  disease  under  discussion — no  dark  spots,  no 
falling  out  of  the  hair,  no  tightness  of  the  skin  ;  and,  moreover,  this  site 
of  atrophy  is  very  rare  in  progressive  muscular  atrophy.  Facial  paralysis 
is  nearly  always  of  sudden  appearance,  and  the  muscles  lose  their  electric 
contractility. 

Prognosis — As  far  as  I  can  learn  no  deaths  have  been  reported,  and 
no  cures  by  drugs.  From  its  progressive  nature  (and  particularly  if  we 
concede  it  to  be  a  central  disease  of  a  degenerative  character)  the  prog- 
nosis must  be  bad.  though  two  or  three  cases  have  been  related,  however, 
in  which  there  was  an  arrest  of  the  atrophy  without  any  treatment.  In 
Helot's1  case  the  disease  became  stationary  after  a  year. 

1  Quoted  by  Draper,  Am.  Psy.  Journal,  Feb.  1876. 


PSEUDO-HYPERTROPHIC    MUSCULAR    PARALYSIS.  269 

Treatment. — Electricity  is  indicated,  but  its  use  has  only  once  been 
attended  by  slight  improvement  in  the  hands  of  Moore,1  who  reported  a 
case  Avhich  was  benefited. 


PSEUDO-HYPERTROPHIC  MUSCULAR  PARALYSIS. 

Synonyms — Myosclerotic  paralysis  ;  Sclerose  musculaire  progressive 
(Requin)  ;  Lepomatosis  musculorum  luxuriam  (Heller). 

Though  first  described  by  two  Italians,  Coste2  and  Gioga,  in  1838,  and 
subsequently  by  Meryon3  in  1852,  the  affection  attracted  little  notice  till 
1868,  when  Duchenne4  presented  to  the  profession  a  critical  analysis  of 
thirteen  cases.  It  is  hardly  worth  while  to  enter  upon  the  discussion  of 
what  has  been  published  since  the  appearance  of  Duchenne's  book.  Suffice 
it  to  say  that  Clymer,5  Ingall,6  and  Webber,?  Pepper,8  S.  Weir  Mitchell,9 
Hammond,10  Drake,11  Gerhard,12  and  Poore,13  in  America,  and  Barlow,1*  of 
Manchester,  in  England,  have  all  reported  cases;  and  I  find,  in  the  little 
brochure  of  the  latter  writer,  the  records  of  additional  cases  by  Heller,15 
Seidel,16  Wernich,17  Scheltzemberser,  and  other  Continental  writers.  So 
far  nearly  one  hundred  cases  have  been  reported. 

Symptoms — Duchenne  details  the  symptoms  in  the  following  order: — 

1.  In  the  beginning  feebleness  of  the  lower  limbs.  2.  Lateral  balanc- 
ings of  the  trunk  and  widening  of  the  legs  during  walking.  3.  A  pecu- 
liar curvature  of  the  spine,  or  saddle-back,  both  in  walking  and  standing. 
4.  Talipes  equinus,  with  an  over-extension  of  the  first  phalanges  of  the 
toes.  5.  Apparent  muscular  hypertrophy.  6.  Stationary  condition.  7. 
Generalization  and  aggravation  of  the  paralysis. 

In  illustration  of  the  progress  of  the  disease,  I  may  present  a  very  well 
marked  case,  which  I  was  permitted  to  examine  by  Dr.  V.  P.  Gibney. 

F.  E.  M.,  aged  13.  Previous  health  excellent,  her  only  illnesses  being 
whooping-cough  at  the  age  of  nine  months,  and  scarlet  fever  a  year  ago, 
which  was  followed  by  some  otitis.  Her  family  history  is  good,  as  far  as 
nervous  disease  is  concerned.  Her  father  died  of  phthisis,  and  her  mother 

I  Op.  cit.  2  Quoted  by  Poore. 

3  Trans,  of  Med.-Chir.  Soc.  1852,  quoted  by  Poore  and  Barlow. 

4  De  1' Electrisation  localisee. 

5  Clymer's  Appendix  to  Aitkin's  Practice,  1868,  and  Med.  Record,  1870. 

6  Boston  Med.  and  Surg.  Journ.,  1870. 

7  Phil.  Med.  Times,  June  and  July,  1871. 

8  Photo.  Review,  Oct.  1871.  9  Op.  cit.,  1st  ed. 
10  Phil.  Med.  Times,  Aug.  29,  1874. 

"  Ibid.,  Oct.  16,  1875  (previously  reported  by  Mitchell). 

12  X.  Y.  Med.  Journ.,  June,  1875. 

13  On  Pseudo-hyper.   Paralysis,   Liverpool   and   Manchester  Med.  and   Surg. 
Reports,  vol.  iv. 

II  Deutsches  Archiv  fur  Klin.  Med.,  torn.  i.  1865.         l5  Centralblatt,  1867. 
16  Deutsches  Arehiv  fur  Klin.  torn,  ii.,  1864.  n  Quoted  by  Barlow. 


270  DISEASES    OF    THE    SPINAL    CORD. 

is  alive  and  healthy.  Her  ancestors  were  long-lived  people.  She  tells  us 
of  an  injury  received  in  1870,  a  boy  having  fired  a  brick  at  her,  which 
struck  her  'in  the  small  of  the  back.  No  fever  or  pain  preceded  her 
present  trouble.  Her  disease  was  of  gradual  development,  and  the  hyper- 
trophy followed  the  injury  which  has  just  been  alluded  to.  At  the  end  of 
six  months  she  found  it  difficult  to  go  up  stairs,  and  her  helplessness  in- 
creased until  the  time  of  admission  into  the  Hospital  for  Ruptured  and  Crip- 
pled April  7,  187G.  The  following  history  was  then  taken:  Complexion, 
light;  hair,  brown ;  eyes,  hazel.  She  is  small  for  her  age,  though  well 
developed.  She  stands  with  abdomen  prominent,  chest  and  head  thrown 
backwards;  walks  with  an  unsteady,  waddling  gait.  Upper  extremities, 
with  exception  of  elbow-joints,  which  permit  extension  beyond  an  angle 
of  180°,  normal.  From  the  sixth  dorsal  to  the  sacrum  there  is  a  lordosis 
of  three  inches,  the  point  of  greatest  incurvation  being  at  the  third  lum- 
bar vertebra.  There  is  tenderness  on  deep  pressure  over  the  twelfth  dor- 
sal vertebra,  while  both  trochanters  stand  out  prominently,  and  the  limbs 
are  widely  separated,  and  there  seems  to  be  no  trouble  about  the  hip- 
joints.  There  is  marked  diminution  in  power  of  the  extensors  of  the  legs, 
preventing  her  from  holding  the  limb  at  a  right  angle  to  the  body.  There 
is  no  marked  loss  of  power  in  the  flexors.  But  there  seems  to  be  some 
loss  of  power  in  the  anterior  foot  muscles ;  no  comparative  atrophy  of  limbs. 
The  muscles  of  the  back  seem  small  and  poorly  nourished.  The  girl  has 
difficulty  in  arising  from,  or  assuming  the  sitting  posture.  The  lordosis 
can  be  overcome  by  the  voluntary  act  of  stooping  forward. 

Treatment — Spinal  brace  to  restore  normal  form,  and  electricity. 

Through  the  kindness  of  Dr.  Virgil  P.  Gibney,  I  was  permitted  to  ex- 
amine the  patient.  I  found  her  to  be  a  rather  well-nourished  girl.  I  was 
immediately  struck  by  her  gait,  which  was  characteristic  of  pseudo-hyper- 
trophic  paralysis.  The  feet  were  planted  widely  apart,  and  when  propul- 
sion was  attempted  the  whole  pelvis  was  seemingly  twisted,  and  the  leg 
clumsily  swung  forward.  The  body  swayed  from  side  to  side,  the  abdomen 
was  prominent,  and  the  shoulders  drawn  back,  so  that  the  extreme  lordosis 
described  so  clearly  by  Uuchenne  was  very  beautifully  shown.  When 
stripped,  this  exaggerated  curve  was  found  to  be  very  great.  A  plumb 
line  held  at  the  seventh  cervical  spine  fell  about  four  inches  back  of  a  line 
drawn  across  the  upper  edge  of  the  sacrum.  When  my  hand  was  placed 
upon  her  abdomen,  and  an  attempt  was  made  to  force  her  to  stand  erect, 
the  nates  were  immediately  thrown  backwards,  and  she  would  have  pitched 
forward  if  not  supported.  When  she  attempted  to  walk,  the  pelvis  seemed 
to  be  lifted  on  the  side  of  the  limb  which  was  raised,  and  at  the  same  time 
the  corresponding  side  of  the  abdomen  became  quite  flat.  Her  gait  was 
waddling,  and  she  progressed  very  slowly.  There  was  some  spinal  ten- 
derness, but  no  other  disturbance  of  sensibility  either  in  the  sound  or  hy- 
jK-rtrophicd  muscles.  The  latter  were  those  of  the  back  of  the  leg,  which 
wen-  much  larger  on  both  sides  than  they  should  have  been,  and  were 
quite  hard  and  in  marked  contrast  to  the  other  muscles  of  the  body,  which 
were  flabby  and  poorly  nourished.  The  muscles  of  both  thighs  at  the 
inner  side  seemed  to  be  atrophied,  as  were  all  the  muscles  of  the  back ; 
but  the  arms  were  of  normal  contour,  and  apparently  unaffected.  There 
was  considerable  loss  of  power  in  the  lower  extremities,  the  patient  being 
unable  without  great  effort  to  rise  from  her  chair,  and  when  she  attempted 
to  do  so  she  planted  her  feet  widely  apart  and  approximated  her  knees. 
The  color  of  the  skin  was  rather  darker  than  it  should  be,  and  especially 


PSEUDO-HYPERTEOPHIC    MUSCULAR    PARALYSIS.  271 

on  the  feet,  legs,  and  hypertrophied  calves  was  there  mottling  and  imper- 
fect incubation.  No  difference  in  tactile  sensibility  could  be  noted.  Meas- 
urements of  different  parts  gave  the  following  results: — 

About  shoulders         ........     29  inches. 

About  waist      .........     24 

Middle  of  right  thigh 14 

Middle  of  left  thigh 13£ 

Right  thigh,  just  above  knee     .         .         .         .         .         .11 

Left  thigh,  just  above  knee        .         .         .         .         .         .12 

Right  calf 12 

Left  calf 12 

A  case  reported  to  me  by  my  friend  Dr.  G.  H.  Swazey  is  the  following. 
This  patient  was  also  seen  by  Dr.  J.  Lewis  Smith : — 

J.  D.,  aged  2  years  8  months.  Has  always  been  a  healthy  boy  until 
four  weeks  ago,  when  it  was  noticed  that  he  seemed  weak  in  his  legs, 
especially  in  the  morning,  or  after  sitting  awhile.  Has  not  complained 
of  any  pain.  When  the  child  walks,  it  is  in  a  peculiar  wabbling  sort  of 
a  way,  with  his  legs  wide  apart,  and  his  shoulders  carried  well  back.  He 
cannot  stand  well  with  his  legs  close  together,  but  soon  totters  and  falls. 
After  he  has  walked  a  while  this  peculiarity  of  gait  is  not  so  perceptible. 
The  left  leg  measures  around  the  calf  eight  and  one-eighth  inches,  right 
leg  around  the  calf  eight  inches.  Just  above  the  knee  left  leg  measures 
nine  and  a  quarter  inches ;  right  leg,  same  place,  nine  and  one-eighth 
inches. 

The  weakness  in  the  legs  has  been  steadily  increasing  from  the  first. 
The  grandmother  of  the  child  on  the  maternal  side  has  epilepsy  ;  the  grand- 
mother on  the  father's  side  has  what  the  mother  calls  weak  spells,  appa- 
rently of  an  epileptic  character.  An  aunt  and  uncle  on  the  father's  side 
have  epilepsy,  and  there  is  also  a  history  of  syphilis  in  the  family.  The 
mother  has  had  miscarriages,  apparently  due  to  that  cause.  The  father 
has  had  eruptions  and  other  symptoms.  March  28th  commenced  treat- 
ment with  the  faradic  current  to  the  muscles,  which  was  continued  three 
times  a  week  for  six  weeks  ;  the  disease  slowly  progressing.  At  this  time 
the  patient  left  off  coming,  and  has  not  since  been  seen. 

Weakness  of  the  lower  extremities  is  one  of  the  earliest  symptoms,  and 
is  gradual  in  its  appearance,  and  not  preceded  by  fever,  as  is  generally 
the  case  in  infantile  spinal  paralysis.  This  impairment  of  power  may 
begin  imperceptibly,  and  first  attract  the  attention  of  the  parent  by  the 
inability  of  the  child  to  walk  at  the  usual  time,  or  may  appear  subsequently, 
the  child  falling  frequently  or  moving  clumsily.  In  Poore's  collection  of 
85  cases,  it  is  shown  that  "3  never  walked  at  all,  24  never  walked  well, 
1  is  reported  as  coming  on  gradually,  52  walked  well  at  first,  and  in  5 
cases  no  mention  is  made  of  the  period  of  walking."  "  Of  those  who  walked 
well,  2  began  to  walk  at  eighteen  months,  3  at  two  years,  3  at  two-and-a 
half  years,  4  at  four  years,  1  at  five,  and  5  are  reported  as  walking  late 
and  badly." 

Duchenne  and  Drake  reported  cases  in  which  convulsions  were  the  be- 
ginning of  the  disease.  Pain  in  the  calves  of  the  legs  or  back  is  some- 
times the  first  symptom,  but  is  by  no  means  one  to  expect  as  a  rule.  The 
appearance  of  the  patient  is  most  striking.  The  belly  seems  to  be  thrown 


272 


DISEASES    OF    THE    SPINAL    CORU. 


out,  the  lumbar  curve  is  increased,  and  the  feet  are  widely  separated. 
When  the  child  attempts  to  walk,  his  movements  are  very  much  like  those 
which  we  might  expect  to  see  in  an  individual  laboring  through  a  quag- 
mire. There  is  a  certain  amount  of  waddling,  the  legs  being  separated, 
and  the  feet  planted  at  some  distance  apart.  In  progression  the  body  is 
inclined  to  the  side  on  which  the  foot  is  planted,  and  there  is  some  jerk 
made  in  the  effort  to  carry  the  foot  forward.  The  patient  rises  from 
the  sitting  posture  with  some  difficulty,  as  there  is  great  impairment  of 
the  extensor  muscles  of  the  spine.  This  weakness  is  the  cause  of 
the  difficulty  in  keeping  his  balance.  The  next  stage  of  the  disease  is 
the  development  of  the  hypertrophy.  Very  often  this  change  is  an 

Fig.  39. 


The  Spinal  Carve  In  Pseudo-Hypcrtrophtc  Paralysis. 

early  one,  and  may  follow  closely  after  the  commencement  of  the  impaired 
motor  power.  The  calves  are  generally  first  enlarged,  and  this  enlarge- 
ment may  begin  with  the  difficulty  in  walking,  or  within  a  period  any- 
where from  six  months  to  several  years  after  the  beginning  of  the  disease. 
This  enlargement  is  not,  however,  always  conh'ned  to  the  calves,  but  may 
affect  the  other  muscles  of  the  lower  extremities,  or  even  those  of  the 
upper.  The  glutei,  gastrocnemii,  deltoid,  and  many  other  muscles  have 
been  involved  in  cases  reported  by  different  observers.  When  the  mus- 
cles are  contracted,  they  stand  out  quite  prominent,  and  in  one  of  the 
cases  reported  by  Barlow1  the  child's  appearance  resembled  that  of  the 

1  Op.  cit.,  p.  11. 


PSEUDO-HYPERTROPI1IC    MUSCULAR    PARALYSIS.  273 

Farnese  Hercules.  The  child  is  unwieldy  and  awkward,  and  though 
there  is  at  this  stage  some  increase  in  strength  of  some  of  the  members 
used  in  locomotion,  the  child  does  not  seem  to  have  very  much  motor 
power,  for  he  can  scarcely  walk.  The  muscles  not  hypertrophied  may 
undergo  an  atrophic  change,  greatly  adding  to  the  deformity.  In  regard 
to  the  talipes  that  may  be  produced,  the  extensors  are  agitated  by  spas- 
modic contractions,  which  become  more  aggravated  as  the  attempt  to  walk 
is  persisted  in,  so  that,  after  a  few  steps,  the  child  is  quite  likely  to  fall. 
The  skin  may  often  be  greatly  discolored  in  patches  just  as  it  is  in  infantile 
paralysis,  and  Duchenne  has  called  attention  to  this  mottling,  which 
is  due  to  modified  cutaneous  circulation,  and  is  seen  especially  during  the 
later  stages  of  the  disease.  It  is  more  often  confined  to  the  lower  ex- 
tremities, and  the  patches  which  at  first  appear  as  bi'ight  red  discolorations 
gradually  become  more  dusky  as  they  are  exposed  to  the  air.  This  mot- 
tling is  increased  by  muscular  action,  and  in  certain  regions  was  found  by 
Benedikt  to  be  connected  with  local  sweating.  The  temperature  of  the 
hypertrophied  muscles  is  higher  by  a  degree  or  two  than  those  that  are 
atrophied ;  and  in  the  early  stages  electric  contractility  is  rarely  affected, 
but  in  the  later  it  is  greatly  diminished.  Of  course,  this  depends  upon 
the  fatty  substitution  which  the  muscular  tissue  has  undergone,  for  but  a 
small  amount  of  normal  muscular  fibre  remains  to  be  called  into  action  by 
the  electric  stimulus. 

Causes Beyond  the  question  of  heredity  it  is  impossible  to  go  in 

our  search  for  causes.  One  or  two  cases,  however,  are  mentioned  by 
foreign  observers  in  which  injury  preceded  the  disease.  Kesteven1  re- 
ported one  of  these,  and  in  this  case  the  hypertrophy  appeared  at  the 
fifteenth  year. 

Poore's  table2  includes  the  following  examples  of  heredity : — 

"  In  two  cases  a  maternal  uncle  and  aunt  had  this  disease. 

"  In  one  case  three  maternal  uncles  and  aunts  had  this  disease. 

"  In  one  case  one  maternal  uncle  and  one  half-uncle  had  this  disease. 

"In  one  case  three  maternal  half-brothers  had  this  disease. 

"  In  one  case  a  maternal  half-brother,  three  maternal  uncles,  and  other 
members  on  the  mother's  side,  had  shown  the  symptoms  of  pseudo-hyper- 
trophic  paralysis. 

"In  thirty-seven  instances,  two  or  more  belonged  to  the  same  family. 
It  will  be  observed  that  it  is  only  on  the  mother's  side  that  this  hereditary 
influence  is  transmitted;  while  the  disease  shows  itself  almost  exclusively 
in  the  males.  Thus,  in  a  case  reported  by  Duchenne,  the  mother,  while 
she  escaped,  transmitted  the  disease  to  the  children  of  her  marriage.  The 
same  fact  is  stated  in  Foster's  case. 

"In  one  case  a  maternal  grandfather  was  hemiplegic. 

"In  one  case  a  paternal  grandfather  was  insane. 

"In  one  case  a  father  was  insane. 


1  Journal  of  Mental  Science,  vol.  xvi.,  April,  1871,  p.  48. 

2  Loc.  cit. 
18 


274  DISEASES    OF    THE    SPINAL    CORD. 

"  In  one  case  a  father  was  intemperate. 

"  In  one  case  two  brothers  died  of  granular  meningitis. 

"  In  one  case  a  brother  was  an  idiot. 

"In  fifteen  cases  of  the  eighty-five  the  family  history  was  good. 

"In  thirty-three  cases  no  mention  of  family  history  is  made." 

Pathology  and  Morbid  Anatomy — According  to  Barlow,  the 
first  examination  of  the  muscles  in  pseudo-hypertrophic  paralysis  was 
made  by  Greisinger  and  Billroth  in  1865.  Greisinger  excised  a  small 
portion  of  the  left  deltoid,  which  was  hypertrophied  and  paralyzed, 
and  microscopically  examined  the  muscle,  which  resembled  adipose 
tissue.  He  found  the  fasciculi  in  a  perfect  state,  but  surrounded  by  fat. 
Kulenbcrg1  and  Conheim2  found  the  muscular  fibres  reduced  to  fully  one- 
sixth  their  normal  size,  and  in  some  localities  there  were  masses  which 
they  supposed  were  the  sheaths  of  empty  sarcolemmae. 

Auerbach3  found  hypertrophy  of  the  muscular  fibres,  and  an  increased 
development  of  nuclei,  but  no  interstitial  fat  deposit ;  but  this  was  in  a 
patient  who  died  during  the  early  stages  of  the  disease.  Berger's*  expe- 
rience was  identical  in  an  early  case.  Charcot5  examined  a  case  (that 
seen  by  Berger),  and  found  the  psoas  in  a  state  of  primary  alteration. 

Fig.  40. 


I 

Appearance  of  Muscular  Tissue.     (Charcot.) 

The  primitive  muscular  bundles  were  separated  by  broad  spaces  of  con- 
nective tissue  containing  cells  of  a  spindle  shape,  and  nuclei.  Other 
muscles  were  likewise  affected.  The  pectoral  muscles,  and  those  having 
a  sacro-lumbar  attachment,  contained  fewer  nuclei,  and  the  internuclear 
spaces  were  filled  with  wavy  connective  tissue.  In  muscles  which  had 
undergone  still  more  advanced  degeneration,  there  was  some  evidence 


1  Archiv  fUr  Heilkunde,  1865. 

1  Verhandhinjr  der  Berliner  Med.  Ges.  i.,  pp.  101-205. 

3  Viirhow,  Areliiv.,  vol.  iii.  p.  224. 

4  Deutsche  Archiv  fiir  Klin.  Med.,  1872,  p.  303. 

5  Archiv.  de  Physiol.,  etc.,  1872,  p.  1. 


PSEUDO-IIYPERTROPHIC    MUSCULAR    PARALYSIS.  275 

of  fatty  deposit.  In  this  case  he  witnessed  three  stages  of  degene- 
ration. In  the  earliest  there  was  atrophy  of  muscular  bundles,  indistinct 
longitudinal  striae,  and  sometimes  transverse  strias.  The  sarcolemmae  were 
filled  with  a  hyaline  substance. 

Duchenne1  denies  the  existence  of  empty  sarcolemmae,  and  regards  the 
enlargement  due  to  an  increase  of  connective  tissue  containing  fat-cells. 

Diagnosis — Progressive  muscular  atrophy  seems  to  be  the  only  dis- 
ease with  which  this  condition  may  be  mistaken.  If  the  patient  is  seen 
at  a  time  when  the  conditions  of  atrophy  and  hypertrophy  coexist,  it  is 
not  always  easy  to  tell  whether  there  is  an  increase  of  volume,  or  simply 
an  atrophic  condition  of  some  muscles,  while  others  are  of  normal  size ; 
but  the  other  symptoms  alluded  to,  the  exaggerated  lumbar  curve,  and 
the  waddling  walk,  should  settle  the  question  of  diagnosis.  Progressive 
muscular  atrophy  is  also  generally  a  disease  which  rarely  appears  at  so 
early  a  period  as  does  pseudo-hypertrophic  paralysis.  Increase  of  size 
from  determination  of  blood  to  a  muscle,  such  as  that  reported  by  Maun- 
der,2 and  sometimes  fatty  development,  without  paralytic  symptoms,  may 
deceive  the  incautious. 

Prognosis. — The  disease  is  slowly  progressive,  and  death  occurs 
generally  from  some  other  disease.  Poore  reports  thirteen  deaths. 
Phthisis,  pleuro-pneumonia,  uncomplicated  pneumonia,  and  croup  appear 
to  have  carried  off  most  of  these  cases ;  and  it  seems  as  if  pulmonary  dis- 
ease bore  some  special  relation  to  organic  disease  of  the  cord,  particularly 
when  trophic  disorder  accompanies  such  disease.  In  several  of  the 
spinal  affections,  especially  when  the  anterior  cornua3  are  affected,  there  is 
generally  the  development  of  phthisis  or  other  pulmonary  maladies.  The 
deaths  that  have  been  reported  occurred  rarely  before  the  eighth  year  of 
the  disease,  and  generally  between  the  fourteenth  and  thirtieth. 

Treatment Duchenne  reports  two  cures  by  the  faradic  current. 

This  seems  to  be  the  only  remedial  measure  that  promises  anything  at 
all.  The  abolition  of  fatty  food  might  be  recommended,  and  massage 
should  be  employed  at  least  every  day.  The  well-known  fact  that  phos- 
phorus produces  fatty  degeneration  should  contraindicate  its  use. 

1  De  1' Electrisation  localii-ee,  Paris,  1872,  3d  edition,  p.  604. 

2  Med.  Times  and  Gazette,  March  27,  1862. 


276  DISEASES    OF    THE    SPINAL    CORD. 


CIIAPTEK    XI. 

DISEASES  OF  THE  SPINAL  CORD  (CONTINUED) 
POSTERIOR  SPINAL  SCLEROSIS. 

Synonyms Progressive  locomotor  ataxia ;  Tabes  dorsalis  ;  Ataxie 

loeomotrice  progressive  ;  Locomotor  asynergia,  etc. 

When  induration  of  the  posterior  columns  of  the  cord  takes  place,  we 
are  furnished  with  a  very  interesting  and  striking  train  of  symptoms,  which 
are  chiefly  expressed  by  pronounced  disturbance  of  the  locomotory  func- 
tions, and  defects  in  coordination  and  sensation. 

Symptoms After  exposure  or  prolonged  dissipation,  the  individual 

may  first  notice  the  commencement  of  the  disease  by  fulgurating  pains 
which  dart  from  the  feet  up  the  legs  and  thighs,  and  for  the  time  he  may 
suppose  he  has  simply  neuralgia.  These  pains  are  worse  at  night,  and 
may  be  aggravated  by  damp  or  cold  weather.  They  appear  and  disappear 
rapidly,  and  Clarke1  calls  attention  to  their  tendency  to  move  suddenly 
from  one  place  to  another;  remaining  located  in  one  spot  for  some  hours  at 
a  time,  and  then  shifting  to  another.  They  may  shoot  through  the  soles 
of  the  feet,  the  inner  part  of  the  legs,  the  knees,  or  even  the  thighs.  After 
a  time,  which  varies  from  a  few  weeks  to  two  or  more  months,  there  may 
be  a  most  disagreeable  sensory  change  of  a  lesser  grade,  which  is  confined 
to  the  feet.  When  walking,  the  patient  complains  that  "  the  ground  feels 
as  if  it  were  covered  by  fur,  or  a  padded  cushion."  Sometimes  the  sensa- 
tion is  likened  to  that  produced  by  a  stocking  down  at  heel,  or  as  if  his 
shoe  >vas  filled  with  sand ;  or,  again,  as  if  he  were  walking  in  the  air. 
There  is  no  loss  of  muscular  power,  nor  general  loss  of  sensibility,  in  the 
preponderance  of  cases  ;  but  there  only  seems  to  be  a  perversion  of  tactile 
sensibility,  and  that  only  limited  to  the  sense  of  contact.  Heat  and  cold 
are  appreciated,  but  the  shape  or  size  of  the  cold  or  warm  object  cannot 
be  jK'rceived  by  the  tactile  sense  alone.  Painful  impressions  are  appre- 
ciated, but  this  is  all.  Circulation  becomes  sluggish  in  the  limbs,  and 
subjective  cold  is  felt  in  the  lower  extremities.  If  the  individual  is 
seated,  and  the  hand  of  the  examiner  be  held  against  the  sole  of  the  boot 
when  the  patient's  thigh  is  flexed,  it  will  be  found  that  he  is  generally 
quite  able  to  extend  the  leg  forcibly,  but  there  may  be  sometimes  a 
slight  loss  of  power  in  subsequent  stages  when  the  anterior  parts  of  the 
cord  become  affected.  In  the  early  stages  of  what  may  be  called  the 
descending  form,  there  are  various  ocular  troubles.  Amblyopia,  strabis- 
mus, or  diplopia  is  among  the  more  common,  and  it  is  not  unusual 


1  St.  George's  Hospital  Reports,  1866. 


POSTERIOR    SPINAL    SCLEROSIS.  277 

to  find  some  atrophy  of  the  optic  disk  of  either  one  or  both  eyes.  In  both 
forms  of  sclerosis  of  the  cord,  ascending  as  well  as  descending,  it  is  neces- 
sary for  the  patient  to  look  at  the  objects  which  surround  him  in  order 
that  he  may  preserve  his  equilibrium.  If  he  shuts  his  eyes,  he  is  apt  to 
topple  over ;  and  it  is  utterly  impossible  for  him  to  walk  in  the  dark  with- 
out holding  on  to  something  for  support.  The  patient  very  often  finds 
that  when  he  closes  his  eyes,  as  he  is  about  to  wash  his  face,  he  is  quite 
apt  to  pitch  forward  against  the  wall.  This  test  is  an  important  one,  and 
if  he  is  able  to  stand  with  his  heels  and  toes  approximated  and  his  eyes 
shut,  it  may  be  inferred  that  either  his  disease  has  not  advanced  to  a  seri- 
ous extent,  or  that  it  is  not  locomotor  ataxia  at  all.  The  early  ocular 
trouble  is  strabismus,  which  is  an  inaugural  symptom,  and  is  very  often 
accompanied  by  amblyopia  ;  and  if  the  strabismus  be  single,  the  ambly- 
opia  will  be  on  the  same  side.  Various  paralyses  of  cranial  nerves  may 
also  follow,  and  ptosis  is  not  an  unusual  symptom.  Nothnagel1  publishes 
the  notes  of  a  case  where  hyperaesthesia  of  the  parts  supplied  by  the  fifth 
nerve  was  a  prominent  symptom.  The  lost  power  for  localization  is  not 
uncommonly  associated  with  this  disease.  With  closed  eyes  the  individual 
is  unable  to  place  the  tip  of  his  finger  on  his  nose,  or  upon  any  desired 
small  point ;  and,  when  told  to  touch  the  point  of  a  pin  held  by  an  ob- 
server, he  will  be  unable  to  do  so,  his  finger  missing  the  mark.  When 
awaking,  he  is  often  undecided  as  to  the  whereabouts  of  his  legs,  or  some- 
times feels  for  a  moment  that  he  has  none,  and  needs  the  aid  of  vision  to 
see  that  there  are  such  members.  The  nerve-fibres  in  the  posterior 
columns  lose  their  facility  for  the  conduction  of  sensory  impressions ; 
and  it  is  sometimes  several  seconds  before  an  impression  made  at  the  peri- 
phery is  received  at  the  sensorium,  and  appreciated  by  the  individual.  A 
symptom  sometimes  found  in  this  disease,  as  well  as  in  myelitis,  is  the 
sense  of  constriction  which  is  referred  to  the  waist.  The  bowels,  in  the 
early  stages,  are  generally  confined ;  and  there  is  some  loss  of  control 
over  the  bladder,  and  constant  desire  to  empty  that  organ.  Romberg 
calls  attention  to  the  fact  that  the  stream  seems  to  have  no  force,  but  falls 
to  the  ground  on  leaving  the  meatus.  The  individual  is  also  troubled 
by  erections  during  the  early  stages,  and  there  is  greatly  increased  sexual 
power.  This,  however,  is  diminished  towards  the  end  of  the  disease,  and 
in  males  impotence  follows. 

Irritability  of  temper,  occasional  mental  disturbance,  and  loss  of 
memory  are  not  rare  evidences  of  intellectual  failure,  and  occur  at  differ- 
ent stages.  The  electro-muscular  irritability  seems  to  be  rather  increased 
than  diminished,  and  reflex  action  is  usually  exaggerated.2  The  locomo- 
tory  trouble  appears  quite  early,  and  is  one  of  the  most  distressing  fea- 
tures of  the  disease.  It  begins  by  an  awkwardness  in  progression,  and 

1  Berlin  Klin.  AVoch.,  xvii.  18G5. 

2  Westphall  has  recently  shown  that,  when  the  legs  are  crossed,  if  the  tendon  of 
the  rectus  femoris  on  the  side  of  the  suspended  leg  be  struck,  a  contraction  of  this 
muscle  will  follow,  and  the  suspended  leg  will  be  agitated.    In  locomotor  ataxia, 
this  is  not  the  case. 


278  DISEASES    OF    THE    SPINAL    CORD. 

the  feet  fly  out  and  tire  planted  with  a  kind  of  jerk,  the  heel  touching  the 
ground  first.  The  individual  totters,  and  is  eventually  unable  to  walk  at 
all  without  support,  and  the  gait  cannot  be  mistaken  by  any  one  who  h:is 
once  witnessed  it.  The  sense  of  appreciation  of  weight  also  seems  to 
suffer  to  a  decided  degree.  Jaccoud1  found  that  this  is  lost  to  a  great 
extent,  and  that  there  is  a  variation  in  the  power  to  perceive  weights  on 
the  two  sides  of  the  body.  In  one  case  mentioned  by  him,  a  pressure 
equal  to  3000  grammes  was  perceived  on  the  right  side,  and  2HOO  on  the 
left.  The  pains  before  spoken  of  generally  disappear  as  the  disease  be- 
comes confirmed,  though  they  may  List  throughout.  Fibrillary  con- 
tractions are  occasionally  seen  ;  and,  speaking  of  this,  I  have  often  wit- 
nessed a  curious  phenomenon  which  follows  the  use  of  faradism.  1  have 
noticed  that  when  a  muscle  of  one  leg  was  agitated  by  clonic  contraction, 
sometimes  the  same  muscle  in  the  other  leg  would  be  contracted  syn- 
chronously with  that  under  electric  stimulation  :  the  patient  is  gene- 
rally timid,  and  easily  disconcerted  by  any  sudden  noise  or  unexpected 
excitement.  When  crossing  the  street  the  desire  to  avoid  being  run  over 
on  the  approach  of  a  wagon  will  produce  such  demoralization  as  to  prevent 
him  from  taking  another  step,  and  he  sometimes  falls  to  the  ground. 
There  is  rarely  trembling,  unless  the  disease  has  involved  the  upper  part 
of  the  cord,  when  this  symptom,  as  well  as  the  inability  to  appreciate  toj>o- 
graphicsU  points,  will  be  marked.  The  patient  is  generally  worried,  anx- 
ious-looking, and  wo-begone,  and  is  full  of  complaints.  The  disease  may 
last  for  from  five  to  t.wenty  years,  and  the  patient  is  carried  off  by  tuber- 
culosis or  some  intercurrent  pulmonary  affection.  Atrophy  of  all  the 
muscles  of  the  extremities  generally  takes  place  towards  the  end  of  the 
disease,  and  bedsores  and  arthritic  troubles  are  annoying  and  painful  fore- 
runners of  death. 

Charcot  has  called  attention  to  certain  cutaneous  eruptions  which  not 
infrequently  are  found  with  posterior  spinal  sclerosis,  and  which  are 
usually  of  a  papulous  and  pustular  character.  He  mentions  the  case  of 
one  person,  who,  while  under  treatment  at  La  Salpetriere,  presented  large 
patches  of  urticaria,  the  appearance  of  which  was  coincident  with  the 
attacks  of  pain. 

The  eruptions  generally  mark  out  the  course  of  the  nerve  which  is  the 
seat  of  pain.  Hutchinson,  however,  considers  that  this  arrangement  of 
the  eruption  is  usually- misinterpreted,  and  that,  instead  of  the  eruption 
following  the  direction  of  a  nerve-trunk  and  its  branches,  the  corymbiforin 
distribution  of  the  skin-disease  in  reality  corresponds  with  the  course  of 
the  small  vessels. 

C'harcot  and  Raymond,1  in  alluding  to  the  disappearance  of  the  heads 
of  the  long  bones,  relate  the  case  of  a  woman,  aged  52,  who  had  been  ill 
for  many  years.  The  autopsy  revealed  atrophy  of  the  different  processes 
of  the  Immerus,  femur,  tibia,  and  scapula,  with  muscular  degeneration  of 
n  fibrous  character.  In  another  case  there  was  hip-joint  affection,  and 
great  brittleness  of  the  bones,  which  broke  when  subjected  to  inconsidera- 

1  Op.  eit.,  p.  341.  *  Gaz.  M6dicale  de  Paris,  Feb.  19,  1876. 


POSTERIOR    SPINAL    SCLEROSIS.  279 

ble  force,  and  afterwards  united  quite  readily.  During  life  the  evidences 
of  such  arthropathies  are  sometimes  numerous.  They  may  be  illustrated 
by  the  following  case  of  Bourcere.1 

The  patient  was  a  woman  who  entered  La  Charite  April  8,  1875  ;  she 
was  middle-aged,  and  presented  many  of  the  symptoms  of  locomotor 
ataxia.  These  began  about  ten  months  before.  The  left  leg  seemed  to 
be  more  affected  than  the  right.  Three  days  after  admission  the  left 
thigh  and  buttock  began  to  swell  rapidly,  and  in  a  few  hours  the 
swelling,  which  was  not  cedematous  in  the  strictest  sense  of  the  word,  but 
hard  and  not  painful  on  pressure,  reached  its  maximum.  It  extended  as 
far  down  as  the  knee,  where  it  stopped  abruptly.  There  was  no  fluctua- 
tion, nor  any  evidence  of  pus.  The  swollen  part  was  almost  double  the 
size  of  the  other  limb,  while  the  leg  was  shortened,  and  the  foot  was  to 
some  degree  rotated  outwards.  There  was  also  some  swelling  and  hard- 
ness unattended  by  tenderness  in  the  left  iliac  fossa.  The  swelling  disap- 
peared almost  entirely  in  a  week,  when  vaginal  examination  .was  made, 
and  a  hard,  smooth  tumor  was  discovered,  which  apparently  sprung  from 
the  pelvic  bones  of  the  left  side.  Pus  was  soon  afterwards  detected  in  the 
psoas  sheath  above  and  below  Poupart's  ligament.  She  became  pros- 
trated, and  died  on  the  Gth  of  May.  After  death,  decided  osseous  changes, 
to  be  hereafter  described,  were  observed. 

Locomotor  ataxia  may  be  associated  with  progressive  muscular  atrophy, 
or  may  sometimes  terminate  in  general  paresis  of  the  insane.  West- 
phall,  Obersteiner,  and  others  have  written  much  upon  the  relation  of  the 
two  diseases  and  their  possible  coexistence. 

Obersteiner,2  in  an  excellent  paper  upon  Locomotor  Ataxia  and  Mental 
Disease,  considers  that  mental  symptoms  are  found  in  the  greater  propor- 
tion of  cases  of  this  disease,  and  calls  attention  to  the  fact  that  these 
expressions  of  psychical  trouble  may  be  very  slight  ;  still,  an  acute  ob- 
server will  know  that  there  is  a  departure  from  the  normal  intellectual 
condition.  The  patient's  character  is  often  changed  markedly.  I  have 
been  often  astonished  at  the  apathy  of  an  individual,  or,  on  the  other  hand, 
at  his  irritability  of  temper,  the  violence  of  his  anger,  and  his  petulance, 
which  are  more  than  transitory  evidences ;  and  they  are  as  important  symp- 
toms, I  think,  as  neuralgic  pains,  difficulty  of  coordination,  etc.  These 
changes  were  well  displayed  in  a  patient  of  my  own  ;  in  health  he  was  a 
most  amiable,  high-minded  person  ;  in  disease  a  morbid,  bad-tempered, 
whining  wreck.  He  had  been  noted  for  his  gallantry  on  the  field  during 
the  war  ;  but  after  this  disease  had  become  established,  his  character  seemed 
to  undergo  a  complete  transformation.  He  wrangled  with  every  one,  be- 
came irritable  over  petty  things,  and  made  himself  generally  disagreeable. 

Obersteiner  and  Simon3  both  agree  that  these  patients  should  be  exam- 
ined most  carefully,  and  that  the  prognosis  depends  much  upon  the  facts 
relative  to  mental  alteration.  The  latter  says :  "  It  is  not  enough  that 
the  patient  keeps  himself  quiet,  and  answers  the  questions  relative  to  his 

1  Progrfes  M6d.,  Oct.  9,  1875. 

2  Wiener  Medizinische  Woch.,  No.  29,  1875. 
8  Archiv  fur  Psychiatric,  i.  and  ii.,  1875. 


230  DISEASES   OF    THE    SPINAL    CORD. 

age,  how  he  feels,  etc.,  und  does  not  show  marked  delusions ;"  these  are 
not  enough  to  assure  us  that  liis  intellect  is  intact. 

In  regard  to  the  grave  secondary  mental  changes,  Tigges  considers 
general  paralysis  to  be  a  complication,  while  Obersteiner  is  convinced  that 
the  symptoms  of  this  latter  disease  indicate  a  progression  of  the  sclerosis 
upwards.  He  considers  the  lesions  to  be  identical,  and  that  it  is  only  the 
seat  of  the  change  which  has  anything  to  do  with  the  symptom  expressed. 
He  has  also  found,  in  general  paralytics  who  have  died,  a  sclerosis  of  the 
cord. 

M.  Rev  has  observed  nine  cases  of  insanity  associated  with  locomotor 
.ntaxia.  In  three  of  these  the  spinal  sclerosis  preceded  the  cerebral  trouble, 
and  in  one  the  induration  had  extended  from  the  posterior  to  the  lateral 
columns.  He  found  that  the  diagnostic  difference  between  locomotor 
ataxia  combined  with  cerebral  induration,  and  simple  descending  general 
paralysis  of  the  insane,  was  the  walk.  In  the  former  the  patient  could 
not  stand  with  his  eyes  shut,  and  in  the  latter  there  was  no  difficulty  of 
the  kind.  "NVe  may  also  take  for  granted  that  the  walk  of  the  ataxic  is  an 
early  symptom,  and  that  of  the  general  paralytic  a  late  one.  Both  are 
examples  of  defective  coordination,  and  I  think  the  latter  is  unwisely 
called  paralytic. 

The  difficulty  of  turning  around  is  marked  in  ataxia,  and  I  think  it  is 
not  a  prominent  symptom  in  general  paralysis. 

A  case  lately  came  under  my  charge  where  the  sclerosis  of  the  cord 
was  ascending,  and  in  an  incredibly  short  time  the  cerebral  symptoms 
which  indicate  the  general  paralysis  of  the  insane  were  evident. 

M.  F.,  aged  29  ;  United  States.  On  admission  to  the  Epileptic  and 
Paralytic  Hospital,  March  0,  1876,  I  was  immediately  struck  by  the 
woman's  walk,  which  was  ataxic  in  the  extreme;  and  on  questioning  her 
and  her  husband  we  ascertained  that  about  two  years  ago  she  had  neu- 
ralgic pains  in  the  legs  and  feet ;  her  walking  became  defective,  and 
has  continued  so.  Her  mind  was  clear  up  to  a  short  time  ago.  Her 
pupils  are  now  unequally  dilated,  the  left  being  the  largest.  Her  lips 
tremble  distinctly.  Her  tongue,  when  protruded,  also  quivers ;  when 
told  to  keep  it  quiet,  the  motion  is  greatly  exaggerated.  There  is  some 
ptosis  of  the  left  eye.  AVhen  told  to  close  her  eyes,  she  is  unable  to  co- 
ordinate delicate  muscular  movements.  She  cannot  find  the  tip  of  her  nose 
with  her  forefinger  by  more  than  an  inch.  When  her  eyes  are  open,  she 
cannot  touch  small  points,  such  as  the  markings  upon  my  watch-dial. 
When  she  stands  with  her  eyes  closed,  she  topples  over  almost  instantly. 
When  she  walks,  her  toes  are  thrown  out,  and  she  comes  down  upon  her 
heel.  Her  feet  are  planted  far  apart  when  she  attempts  to  stand.  When 
walking  across  the  room,  she  reels,  and  has  difficulty  in  turning  around. 
When  attempting  to  answer  questions,  she  talks  slowly,  each  word  being 
uttered  with  some  effort;  the  words  containing  the  letters  "  f "  and  "p" 
are  explosive,  and  the  lips  seem  to  have  a  great  deal  of  work  to  form  them. 
The  consonants  are  slurred  over ;  for  instance,  the  word  "  man"  is  pro- 
nounced u  mah ;"  the  '*  IV  are  dropped,  as  are  many  other  letters.  Her 
writing  is  very  scratchy  and  irregular,  although  her  husband  says  she 
formerly  wrote  an  excellent  hand.  Mentally  she  is  silly,  and  laughs  im- 
moderately at  wrong  times  and  without  cause.  She  has  no  idea  of  time, 


POSTERIOR    SPINAL    SCLEROSIS.  2Sl 

but  seems  to  know  what  she  is  saying.  She  has  had  several  delusions, 
one  of  which  was  that  she  had  been  home  the  day  before. 

May  12th,  two  months  after  admission Her  walk  is  much  worse  ;  no 

urinary  or  other  difficulty.  There  is  some  festination  ;  pupils  still  uneven. 
The  difficulty  in  speech  has  markedly  increased.  Her  tottering  walk 
is  striking.  "VVe  at  first  thought  she  had  syphilis,  but  this  is  not  so. 
Being  unmanageable  and  restless,  she  was  transferred.  Here  undoubtedly 
was  an  ascending  condition,  beginning  with  the  pains  and  gait  of  loco- 
motor  ataxia,  and  ending  with  several  early  symptoms  of  general  paralysis. 

Charcot1  has  described  a  peculiar  train  of  symptoms  accompanying  the 
pains  of  the  earlier  stages.  These  are  the  crises  gastriques,  which  are 
expressed  by  pains  which  begin  in  the  groins,  and  run  up  the  abdomen  on 
either  side,  finally  becoming  fixed  at  the  epigastrium.  They  are  violent, 
and  occur  during  the  exacerbations  of  lancinating  pain  in  the  lower  ex- 
tremities. During  the  time  they  last,  there  is  violent  palpitation,  vertigo, 
and  vomiting,  the  latter  symptom  occurring  without  relation  to  the  con- 
dition of  the  stomach.  If  there  be  no  food  to  be  expelled  from  that  organ, 
there  may  be  a  quantity  of  frothy  and  bloody  liquid  ejected.  These  crises 
last  two  or  three  days,  and  disappear  quite  suddenly.  Some  observers 
have  noticed  the  appearance  of  ptosis  during  their  existence,  which 
gradually  disappears  ;  and  Stewart2  has  seen  several  cases  in  which  these 
symptoms  varied,  and  instead  of  there  being  pain  which  started  from  the 
groin,  there  was  deep-seated  pain  in  the  dorsal  and  lumbar  regions. 

Reynaud  has  called  attention  to  a  species  of  renal  neuralgia  which  is 
not  at  all  an  uncommon  complication.  One  of  his  cases,  which  was  mis- 
taken for  renal  colic,  presented  lumbar  pain,  vesical  tenesmus,  retraction 
of  the  testicle,  and  other  suggestive  symptoms.  There  was  temporary 
cessation  after  a  few  days,  but  a  second  and  third  attack  followed.  Char- 
cot  and  other  French  writers  have  alluded  to  various  additional  visceral 
disorders,  as  found  with  this  as  well  as  other  organic  spinal  diseases,  and 
the  functions  of  the  kidney  are  sometimes  greatly  disturbed.  I  do  not 
think  that  sufficient  attention  has  been  paid  to  forms  of  hysteria  which 
resemble  locomotor  ataxia.  These,  I  believe,  are  the  cases  which  are 
cured.  Isnard3  has  extensively  considered  the  functional  form  ;  and  Webb, 
of  Philadelphia,  has  reported  a  very  interesting  case  of  genuine  hysteria 
which  counterfeited  the  organic  disease  so  closely  as  to  lead  to  a  primary 
error  in  diagnosis. 

Causes — Dissipation  has  much  to  do  with  the  development  of  this 
terrible  disease,  while  onanism  and  venereal  excesses,  especially,  play  an 
important  part ;  so  we  may  expect  to  find  it  among  men  about  town,  hard 
drinkers,  and  other  people  of  bad  habits.  Injury,  exposure  to  rain  and 
cold,  syphilis,  and  protracted  mental  excitement,  favor  its  origin.  Some 
sudden  exposure,  such  as  a  fall  into  the  water,  or  a  night  in  the  rain,  may 
be  the  exciting  cause,  and  several  of  my  cases  had  such  a  beginning. 

1  Op.  fit.  2  Med.  Times  and  Gazette,  Oct.  7,  18C7. 

3  L' Union  Medic-ale,  131,  134,  135,  137,  141,  142,  1862.  Abst.  in  Lancet, 
Sept.  30,  1875. 


282  DISEASES    OF    THE    SPINAL    CORD. 

Rosentlml1  reported  sixty-five  cases,  forty-six  of  which  were  males  and 
nineteen  females  ;  and  of  this  number  thirty-one  were  traced  to  libidinous 
excesses,  seven  to  exhaustion,  and  twenty-seven  to  cold  and  exposure. 
The  youngest  of  these  patients  was  nineteen,  and  the  oldest  sixty-eight. 
The  ages  at  which  the  disease  appears  is  rarely  before  the  thirtieth, 
and  never  after  the  sixtieth  year.  Heredity  seems  to  have  much  to  do 
with  its  development.  For  instance,  N.  Friedrich8  reports  six  cases  which 
occurred  in  two  families ;  and  two  of  these  patients  were  males,  and  four 
were  females.  The  heads  of  the  families  were  drunkards.  Syphilis,  as  I 
have  said,  is  sometimes  at  the  root  of  locomotor  ataxia,  and  perhaps  is 
the  most  fortunate  cause  to  discover,  as  it  greatly  alters  the  prognosis  of 
the  disease.  It  must  be  understood  that  the  lesion  is  purely  syphilitic ; 
and  the  symptoms  result  simply  from  the  presence  of  a  gummy  infiltration 
or  tumor  in  the  posterior  columns,  and  not  from  any  induced  sclerosis. 

Morbid  Anatomy  and  Pathology — The  cord  of  the  ataxic,  when 
cut  into,  will  present  an  appearance  which  is  distinctive.  The  posterior 
columns  will  be  found  to  be  more  gray  and  dark  than  they  should  be,  and 
there  may  be  hard  deposits  on  either  side  of  the  posterior  fissure.  Be- 
neath the  microscope  the  peculiar  thickening  of  the  connective  tissue  will 
be  found  to  have  taken  place  at  the  expense  of  the  nervous  elements. 
Lockhart  Clarke  thus  tersely  describes  the  changes  that  take  place  :  "  The 
morbid  anatomy  of  locomotor  ataxia  consists  chiefly  of  a  certain  gray 
degeneration  and  disintegration  of  the  posterior  columns  of  the  spinal  cord, 
of  the  posterior  roots  of  the  spinal  nerves,  of  the  posterior  gray  substance 
or  cornua,  and  sometimes  of  the  cerebral  nerves.  A  variable  number, 
and  frequently  in  the  latter  stages  of  the  disease  nearly  all  the  fibres  of 
the  posterior  column  and  posterior  roots,  fall  into  a  state  of  granular 
degeneration  and  ultimately  disappear.  Usually  the  posterior  columns 
retain  their  normal  size  and  shape  in  consequence  of  hypertrophy  of  con- 
nective tissue  which  replaces  the  lost  fibres. 

"In  this  tissue,  at  wide  but  variable  intervals,  lie  imbedded  the  remaining 
nerve-fibres  with  the  de'iris  of  their  neighbors  in  different  stages  of  disin- 
tegration. In  some  places  they  are  severed  into  small  portions,  or  into 
rolls  or  lobular  masses  formed  out  of  the  medullary  sheaths  of  white  sub- 
stance, which  has  been  stripped  from  their  axis  cylinders.  In  other  places 
they  have  fallen  into  smaller  fragments  and  granules,  which  are  either 
aggregated  in  the  line  of  the  original  fibres  or  scattered  at  irregular  dis- 
tances. Corpora  amylacea  are  usually  abundant,  and  oil-globules  of  dif- 
ferent sixes  are  frequently  interspersed  among  them  and  collected  into 
groups  of  variable  shape  and  size  around  the  bloodvessels  of  the  part.  I 
am  inclined  to  believe  from  my  own  investigations  that  in  the  course  of 
the  disease  the  posterior  cornua  of  gray  substance  are  more  or  less  affected, 
and  it  appears  to  me  to  be  a  question  whether  they  are  not  the  first  parts, 
or  at  least  among  the  first  parts  that  are  morbidly  changed.  I  have  also 

1  Wirn,  Mod.  Woch.,  1869,  No.  251. 

2  Virehow'frArchiv,  xxvi.  pp.  391,  433. 


POSTERIOR    SPINAL    SCLEROSIS. 


283 


shown  that  in  some  cases  the  deeper  central  parts  of  the  gray  substance 
are  more  or  less  injured  by  areas  of  disintegration.  These  latter  lesions, 
however,  are  not  essential  to  the  production  of  locomotor  ataxia,  the 
peculiar  symptoms  of  which  depend  solely  on  lesions  of  the  posterior 
columns  of  the  posterior  nerve-roots,  and  probably  of  the  posterior  cornua. 
The  cases  in  which  they  occur  may  be  considered  as  mixed  cases,  partak- 
ing of  the  nature  of  locomotor  ataxia  and  common  spinal  paralysis." 
Charcot  and  Vulpian  consider  sclerosis  of  fillets  or  columns  of  Gall  to  be 
the  essential  lesion  of  the  disease  under  consideration.  These  occupy  the 
space  on  either  side  of  the  posterior  fissure,  and  from  them  pass  the  most 
internal  sensory  roots.  I  do  not  think,  at  this  stage  of  our  knowledge,  that  it 
is  possible  to  make  the  distinction  between  symptoms  indicative  of  sclerosis 
of  the  columns  of  Gall  and  of  other  parts  of  the  posterior  column.  It  has 
been  shown  that  the  nerve-roots  themselves  need  not  necessarily  be 
affected,  although  the  cornua  may  be  degenerated  most  completely.  The 
sclerosed  parts  of  the  cord  in  this  disease  are  more  commonly  the  lumbar 
and  lower  dorsal,  although  the  cervical  portion  may  be  invaded  as  well. 
The  case  mentioned  by  Nothnagel  presented  sclerosis  of  the  entire  poste- 
rior columns.  The  bones  undergo  remarkable  changes,  and  after  death 
the  result  of  such  arthropathic  alterations  may  be  seen  in  atrophy,  exfolia- 
tion, shortening,  and  destruction  of  their  articular  surfaces. 

The    appearance    of    old    fracture    is    admirably  shown    in    Fig.    41, 
which  is  taken  from  Charcot.     The  cranial  nerves  are  not  rarely  atiected, 


Fig.  41. 


Appearance  of  Trophic  Bone  Changes  in  Locomotor  Ataxia.     (Charcot.) 

their  course  being  sometimes  interrupted  by  patches  of  degeneration. 
The  induration  attacks  the  periphery  first,  and  extends  to  the  centre,  and 
the  changes  begin  at  the  point  of  origin  of  the  nerve  and  progress  towards 
its  distal  end.  The  optic  disk  is  nearly  always  found  to  be  atrophied  and 
blanched,  but  there  seems  to  be  no  change  in  the  size  of  the  retinal  ves- 


234  DISEASES    OF    THE    SPINAL    CORD. 

sels.  There  are  often  evidences  of  injection  of  the  investing  membranes  of 
the  cord  or  actual  meningitis,  and  six  cases  which  were  reported  by  Krird- 
rich  presented  opacity,  and  thickening  of  the  pia  mater,  which  was  adherent 
to  the  cord,  and  I  doubt  if  there  are  many  examples  in  which  some  form  of 
meningitis  has  not  existed  at  some  time  or  other.  Charcot1  alludes  to 
the  gray  degeneration  of  the  optic  nerves  as  an  evidence  of  amaurosis  that 
is  so  prominent  a  symptom,  and  he  calls  the  pathological  condition  "  nev- 
rite  parenchymateuse." 

Much  of  the  interest  belonging  to  this  disease  is  connected  with  the 
phenomena  of  incoordination,  and  a  lesion  that  may  affect  the  integrity  of 
the  organs  intended  for  the  transmission  and  reception  of  visual,  auditory, 
or  tactile  impressions  will  result  in  a  loss  of  equilibrating  power.  Accord- 
ing to  Ferrier,  the  apparatus  provided  for  the  maintenance  of  equilibrium 
consists  of:  1,  a  system  of  afferent  nerves  ;  2,  a  coordinating  centre;  3, 
efferent  tracts  in  connection  with  the  muscular  apparatus  concerned  in  the 
action.  Of  course  lesions  of  one  or  all  of  these  parts  must  result  in  a  loss 
of  balancing  power.  Perhaps  the  most  important  factor  in  the  pn-srrva- 
tion  of  equilibrium  is  tactile  sensibility.  The  frog,  deprived  of  his  skin, 
loses  the  power  of  coordination,  for  the  coordinating  centre  is  deprived  of 
the  exciting  organ  from  which  impressions  are  transmitted.  So,  too,  may 
this  loss  follow  sudden  destruction  of  one  of  the  peripheral  organs  of  spe- 
cial sense.  As  has  been  shown  by  Volkmann,  the  exposed  ends  of  the 
nerves  are  not  sufficient  to  transmit  the  sensory  impression,  but  it  is  neces- 
sary that  their  cutaneous  terminations  shall  exist.  When  the  tactile  sen- 
sation in  the  ataxic  is  blunted,  or  the  impressions  are  interrupted  in  their 
upward  course,  as  has  been  held  by  Schiff,  we  have  a  loss  of  coordinating 
power  which  is  a  striking  feature  of  locomotor  ataxia.  It  is  not  neces- 
sary for  consciousness  to  enter  into  equilibration  and  coordination,  for,  as 
we  well  know,  many  acts  are  purely  spinal  in  character,  and  become  auto- 
matic to  some  degree ;  and  walking  is  notably  one  of  these  acquired 
automatic  movements.  Acephalous  monsters  have  performed  a  number 
of  acts  which  were  strongly  reflex ;  and  animals  from  whom  the  brains 
have  been  removed  are  able  to  coordinate  to  a  certain  degree  after  the 
first  shock  of  the  operation  has  passed  by.  In  the  disease  under  consider- 
ation consciousness  enters  to  a  decided  extent  when  the  harmony  of  the 
coordinating  centres  is  lost.  This  consciousness  is  exhibited  in  vertigo, 
and  is  exerted  in  the  ineffectual  effort  to  regulate  the  actions  of  the  limbs, 
the  brain  endeavoring  to  supply  the  lost  automatic  sense.  Broadbent2 
considers  that  there  are  two  coordinating  centres;  one  in  the  cerebellum, 
and  the  other,  as  I  have  stated,  in  the  cord.  Vision  holds  the  same 
relation  to  the  cerebellar  coordinating  power  that  tactile  sensibility  does 
to  the  cord  centre.  For  instance,  a  tight-rope  walker  would  fall  were 
it  not  for  the  aid  of  vision,  although  the  tactile  sensibility  becomes  so 
perfectly  educated  that  it  may  take  the  place  of  the  eyes  in  enabling  the 

1  Logons  sur  le  Syst.  nerveux,  2feme  seri6,  1  fascic. 

2  Brit.  Mod.  Journal,  April.  1875. 


POSTERIOR    SPINAL    SCLEROSIS. 


285 


Fiji.  42. 


performer  to  regulate  his  actions.1  The  tactile  sense  is  of  a  lower  grade, 
and  when  this  fails  the  individual,  as  is  the  case  with  the  ataxic,  requires 
more  than  ever  the  aid  of  vision.  In  the  normal  condition  he  may  close 
his  eyes,  and  still  be  able  to  walk  in  the  dark  with  some  ease ;  but  if  the 
tactile  sensibility  be  affected,  as  it  is  in  the  disease  under  consideration, 
and  if  the  aid  of  his  vision  be  denied  him,  he  is  utterly  helpless  to  regulate 
his  muscular  movements.  In  the  daylight  he  still  has  the  power  of  help- 
ing himself,  for  vision  comes  to  his  assistance.  In  health  this  delicacy 
of  coordination  may  be  trained  to  a  marvellous  degree.  I  have  repeatedly 
witnessed  the  feats  performed  by  a  French  juggler,  which  illustrated  the 
nicety  of  appreciation  of  weight  it  is  pos- 
sible to  arrive  at  by  practice.  He  would 
throw  into  the  air  a  heavy  cannon  ball  and 
a  pellet  of  paper,  alternately  catching  them 
and  tossing  them  up  again,  and  the  mus- 
cular movements  were  regular  and  harmo- 
nious, and  indicated  no  effort  whatever. 
In  locomotor  ataxia  this  power  of  appre- 
ciation is  sometimes  lost  to  a  marked 
degree.  To  the  ataxic  individual  a  four- 
pound  weight  seems  no  heavier  than  one 
of  two  pounds  would  if  he  were  in  nor- 
mal condition,  and  if  his  muscular  move- 
ments were  properly  coordinated. 

The  arrangement  of  the  sensory  fibres 
of  the  posterior  column  is  such  that  a 
lesion  of  either  the  white  or  the  gray  mat- 
ter itself  must  interfere  with  the  conduc- 
tivity of  sensory  impressions.  Lockhart 
Clarke's  histological  researches  have 
thrown  much  light  upon  the  subject. 
According  to  him,  the  posterior  root-fibres 
enter  the  cord  in  three  directions,  some 
passing  in  at  right  angles  to  the  longitu- 
dinal fibres  of  the  posterior  column,  then 
passing  across  the  same  as  well  as  the 
gray  substance,  then  bending  and  continu- 
ing longitudinally  downward,  next  pass- 
ing into  the  gray  matter  of  the  anterior 
cornua,  and  finally  terminating  in  fasci- 
culi which  intermingle  with  the  fibres  of 
the  anterior  roots,  or  extend  into  the  an- 
terior columns.  Other  fibres  (those  of 
the  second  class)  run  across  the  posterior 


The  Course  of  Posterior  Nerve-Roots. 
(Clarke.) 


1  I  have  no  doubt  some  of  my  American  readers  have  witnessed  the  perform- 
ance of  a  tight-rope  walker,  who  goes  through  his  feats  of  balancing  and  walking 
with  bandaged  eyes,  meanwhile  perfectly  preserving  his  equilibrium. 


286  DISEASES    OF    THE    SPINAL    CORD. 

columns,  or  cross  to  the  other  side  of  the  cord  in  the  posterior  commissure, 
or  extend  deeply  into  the  posterior  columns  of  the  same  side ;  and  others 
pass  forward  into  the  gray  matter  of  the  anterior  cornua.  The  third  kind 
of  jK)sterior  spinal  roots  enter  obliquely;  and  certain  fibres  pass  upw;mU 
and  downwards,  and  become  associated  with  fibres  above  and  below  them. 
The  remaining  fibres  take  an  oblique  course,  and  run  upwards  and  down- 
wards, the  greater  number  taking  the  former  direction  and  passing  finally 
into  the  gray  matter.  It  will  be  seen  that  a  lesion  affecting  the  pos- 
terior columns  of  the  cord  will  destroy  the  communication  of  the  nerve- 
roots  with  the  gray  matter,  or  press  upon  the  sensory  fibres,  causing  peri- 
pheral pain.  The  communication  with  the  parts  above  is  destroyed,  and 
should  the  sclerosis  involve  the  anterior  gray  matter  there  may  be  parah  -i< 
and  atrophy.  A  favorite  theory,  accepted  by  many  writers,  is  that  which 
considers  that  there  are  numerous  centres  of  coordination  in  the  cord, 
which  are  connected  by  longitudinal  fibres,  and  that  when  these  fibres  are 
destroyed  there  results  a  species  of  incoordination.  Dieulafoy1  divided  the 
posterior  fasciculi  at  different  heights,  but  without  producing  any  marked 
defects  in  coordination,  which  seems  to  disprove  this  theory. 

Diagnosis — It  is  important  to  distinguish  locomotor  ataxia  from 
chronic  myelitis,  progressive  muscular  atrophy,  chorea,  and  cerebellar 
disease.  The  former  disease  occasionally  resembles  ataxia,  but  with  or- 
dinary care  no  mistakes  need  be  made.  The  paralysis  of  the  first  disease 
is  very  marked,  and  the  implication  of  tl:e  bladder  and  sphincter  ani  causes 
the  patient  to  void  his  urine  and  feces  involuntarily,  which  is  not  the  case 
in  locomotor  ataxia.  The  strong  ammoniacal  odor  of  decomposed  urine  is 
itself  almost  a  sufficient  diagnostic  mark.  There  is  an  absence  of  power 
in  the  legs,  and  none  of  the  pain  which  characterizes  sclerosis  of  the  pos- 
terior columns.  Ocular  trouble  and  incoordination  are  likewise  absent.  If 
the  gait  of  the  two  diseases  be  compared,  it  will  be  found  that  in  the  for- 
mer the  legs  will  be  thrown  out  with  some  degree  of  violence,  and  the 
heel  will  come  down  forcibly.  In  the  paraplegia  of  myelitis,  the  legs  will 
be  drawn  after  each  other,  the  inner  edge  of  the  sole  scraping  the  ground  ; 
and  there  is  often  a  shrug  of  the  body  required  to  bring  the  feet  forwards. 
The  walk  of  the  hemiplegic  is  also  different,  as  one  leg  is  swung  forwards, 
the  toe  describing  an  arc,  or  else  the  foot  is  advanced  in  a  straight  line, 
the  sole  hardly  clearing  the  floor.  Myelitis  in  its  early  stages  sometimes 
resembles  posterior  spinal  sclerosis.  The  pain  in  the  back,  however,  is 
characteristic,  and  the  ulterior  paralysis  and  bladder  trouble  are  sufficient 
in  themselves  to  clear  up  the  diagnosis,  though  the  constricting  band 
about  the  waist  may  excite  our  suspicion.  Cerebellar  disease  has  been 
spoken  of  by  Radcliffe2  as  a  condition  that  may  sometimes  be  mistaken 
for  locomotor  ataxia.  The  movements  are  somewhat  different,  however, 
for  the  patient  rolls  and  sways  to  a  greater  degree,  and  does  not  present 
the  peculiar  jerking  gait  of  the  ataxic.  Local  pain  is  another  symptom 
peculiar  to  the  cerebellar  condition,  and  vomiting  is  also  suggestive  ot 

du  Concours,  1875.  «  Op.  cit.,  vol.  ii.  p.  683.     ( 


POSTERIOR    SPINAL    SCLEROSIS.  281 

this  affection,  but  not  of  locomotor  ataxia.  Progressive  muscular  atrophy 
in  its  earlier  stages  is  apt  to  be  mistaken  for  locomotor  ataxia.  The 
wasting  of  the  muscles  in  anomalous  cases  may  be  imperceptible,  and  the 
unsteadiness  of  the  individual  may  alone  attract  attention.  This,  with 
the  pain,  may  raise  a  doubt  as  to  the  true  nature  of  the  malady.  Syphilis, 
in  some  of  its  forms,  also  occasionally  produces  symptoms  which  are  very 
much  like  those  of  this  disease ;  and  there  may  be  paralysis  of  cranial 
nerves,  with  pain  over  'the  tibia,  which  may  be  misleading,  when  in 
reality  no  spinal  disease  exists. 

Prognosis — Among  the  number  of  cases  reported  by  various  ob- 
servers. I  have  not  found  more  than  one  or  two  well-authenticated  cures. 
Hammond  has  cured  some  lighter  cases,  which  he  does  not,  I  believe, 
really  consider  to  be  genuine  examples  of  locomotor  ataxia  ;  but  others 
have  been  less  fortunate.  A  peculiarity  of  the  disease  is  the  long  inter- 
vals of  improvement  which  occasionally  occur  ;  and  the  disease  may  be 
stationary  for  years,  but  this  is  very  rarely  the  case.  I  know  of  two 
cases  which  were  so  much  improved,  and  remained  so  well  for  three  or 
four  years,  that  I  flattered  myself  that  I  had  cured  them  ;  but  I  have 
since  seen  a  change  for  the  worse  in  both  patients.  Balfour1  presented  a 
case  of  locomotor  ataxia  which  he  claims  to  have  cured.  Pollard2  reports 
a  case  which  began  rather  suddenly,  and  disappeared  quite  rapidly  under 
treatment.  Yidal,3  Duqueit,4  and  Herschell,*  all  report  cures.  Vidal's 
patient,  a  man  of  45,  recovered  in  three  months,  and  Duqueit's  and  Her- 
schell's  cases  I  consider  doubtful  as  regards  diagnosis. 

Treatment — From  the  very  nature  of  the  disease  the  treatment 
must  be  empirical,  and  no  one  remedy  seems  to  have  done  much  good, 
although  nitrate  of  silver  has  been  recommended  by  Wunderlich,  Char- 
cot,  Yulpian,  and  others,  and  has  enjoyed  great  popularity  as  a  remedy. 
Balfour,  already  alluded  to,  states  that  he  cured  a  patient  in  three  months 
by  half-grain  doses  of  this  salt  repeated  three  times  a  day,  and  by  the  use 
of  a  foot-bath  in  which  a  quantity  of  common  salt  had  been  thrown.  The 
feet  were  also  submitted  to  the  influence  of  a  faradic  current  passed 
through  the  water  by  proper  appliances.  The  salts  of  silver  (FF.  77, 
78,  79)  may  be  used  with  considerable  impunity  without  discoloring 
the  skin,  though  an  unnecessary  degree  of  timidity  has  been  shown  in  its 
employment.  It  is  well,  however,  to  begin  with  a  quarter-grain  dose,  and 
it  may  be  increased  to  a  half,  or  even  a  grain,  thrice  daily.6  One  case  of 
my  own  was  greatly  benefited  by  this  drug  in  combination  with  nux 
vomica  (F.  79).  I  have  lately  tried  the  phosphate  of  silver  in  one-third 
of  a  grain  doses,  with  great  success,  and  prefer  it  to  the  nitrate  (F.  80). 
In  administering  the  silver  salts  it  is  well  to  give  them  continuously  for 
several  months,  and  then  permit  an  interval  to  elapse  before  beginning 

1  Brit.  Med.  Journal,  1875.  2  Lancet,  1872,  vol.  i.  p.  437. 

3  (iaz.  des  H6p.  127,  1862.  4  L' Union,  122,  1862. 

5  Bulletin  de  Therapeutique,  Ixiii.,  Oct.  1862. 

6  De  1'emploi  du  nitrate  d' argent  dans  le  traitement  de   1'ataxie  progressive. 
Bull.  Gen.  de  Ther.,  1862. 


288  DISEASES    OF    THE    SPINAL    CORD- 

again.  In  the  early  stages  of  the  disease  I  prefer  the  fluid  extract  of  ergot, 
either  in  combination  with  the  bromide  of  sodium,  or  alone  (FF.  5,  (5.)  It 
certainly  seems  to  control  the  pain.  Among  the  more  efficacious  remedies  to 
which  I  may  allude  is  the  sulphur  bath,  which  is  too  little  used  at  the  present 
day,  and  has  been  praised  by  the  French  writers  especially.1  It  seems 
to  possess,  in  some  cases,  powers  which  are  almost  marvellous.  A  small 
lump  of  sulphide  of  potassium  is  to  be  thrown  into  the  tub  in  which  the 
patient  bathes,  after  which  he  is  to  be  thoroughly  rubbed.  In  regard  to 
electricity,  Meyer  has  reported  several  cures  by  the  galvanic  current. 
Oniinus  has  used  the  inverse  current,  and  I  believe  has  done  some  good. 
The  indication  seems  to  be  that  the  positive  pole  should  be  placed  over 
the  painful  point,  if  one  can  be  found,  and  the  negative  above.  These 
cases  in  which  cures  have  been  wrought  were,  I  infer*ataxic  conditions  of 
a  functional  character.  Faradization  of  the  muscles  of  the  legs  and  thighs 
seems  to  comfort  the  patient  more  than  anything  else.  Duchenne  thinks 
that  the  muscular  anaesthesia  is  benefited  greatly  by  its  use,  and  that  co- 
ordination is  improved.  Dr.  Drinkhard,  of  Washington,2  suggested  that 
strychnine,  injected  hypodermically,  is  a  remedy  which  should  not  be  lost 
sight  of.  In  one  case  it  promptly  relieved  the  pain.  He,  however,  com- 
pares the  dangerous  appetite  of  possible  formation  to  that  which  grows  out 
of  the  medicinal  use  of  large  doses  of  opium,  and  fears  such  trouble.  I  have 
used  the  actual  cautery  to  the  spine  quite  frequently,  and  have  found  that 
constant  revulsive  effect  kept  up  for  some  weeks  not  only  diminished  the 
pains,  but  really  improved  locomotion.  It  should  be  applied  down  the 
whole  length  of  the  back,  on  either  side  of  the  spinous  processes;  and,  after 
the  epidermis  has  shrivelled  off,  subsequent  applications  are  to  be  made. 
Belladonna  and  turpentine  are  recommended  by  Trousseau  (F.  81),  and 
not  only  relieve  the  pain,  but  seem  to  help  any  vesical  trouble  that  there 
may  be.  Should  we  suspect  syphilis,  the  iodide  of  potassium  (F.  20)  will 
be  indicated,  and  a  saturated  solution  should  be  prepared,  and  given  in  in- 
creasing doses  till  forty  or  fifty  grains  are  taken  three  times  a  day.  Above 
all,  it  must  be  remembered  that  nutritious  food,  cod-liver  oil,  and  moderate 
stimulation  are  perhaps  more  important  than  medication.  I  have  observed 
the  necessity  for  quiet  and  rest.  Prolonged  muscular  exercise  is  bad,  and 
drives  are  to  be  preferred  to  walking.  The  patient  should  seek  a  warm 
climate,  for  this  disease  is  affected  by  damp  cold  weather,  very  much  as  is 
phthisis,  and  a  cold  winter  always  tells  upon  the  patient.  The  pains  also 
are  aggravated  by  cold  and  sudden  changes,  and  I  find  Florida  or  other 
Southern  States  to  be  the  most  comfortable  places  for  these  invalids. 
Much  benefit  has  been  derived  from  the  dark  room  treatment,  and  I  saw 
one  gentleman  who  had  been  greatly  improved  by  a  few  months  of  bed  rest 
in  a  dark  chamber. 

Dissipation  thwarts  any  chance  of  success,  and  late  hours  or  a  debauch 
will  produce  a  relapse  some  time  after  encouraging  improvement  has  taken 
place.  Sexual  indulgence  (when  it  is  possible)  is  likewise  to  be  interdicted. 

1  It  has  acted  wonderfully  in  cases  even  of  long  standing,  and  deserves  a 
faithful  trial. 

*  Am.  Jour.  Med.  Sciences,  July,  1873. 


ANTERO-LATERAL    AMYOTROPHIC    SCLEROSIS.  289 

AXTERO-LATERAL  AMYOTROPHIC  SCLEROSIS.' 

Synonyms — Amyotrophic  lateral  spinal  sclerosis  (Charcot).  In- 
flammation of  the  lateral  columns  of  the  spinal  cord,  and  of  the  anterior 
tract  of  gray  matter  (Hammond). 

When  the  anterior  tract  of  gray  matter  and  the  lateral  columns  of  the 
cord  are  conjointly  the  seat  of  destructive  changes,  we  find  permanent 
contractures  following  loss  of  muscular  power  in  both  upper  and  lower  ex 
tremities,  together  with  extensive  atrophy  and  subsequent  bulbar  symp 
torn*. 

Symptoms — The  disease  begins  without  fever;  with  loss  of  power  in 
the  muscles  of  the  upper  extremities,  which  becomes  quite  marked  after  a 
short  space  of  time,  and  then  follows  a  general  atrophy  of  the  muscles  ot 
the  paralyzed  members.  In  this  way  the  malady  differs  from  progressive 
muscular  atrophy,  in  which  one  group  of  muscles,  or  even  a  single  muscle, 
becomes  atrophied  before  others,  and  in  advance  of  any  paralysis.  Char- 
cot  calls  this  wasting  process  "  atrophie  en  masse."  Attendant  upon  the 
paralysis  are  deformities,  and  these  are  highly  characteristic  of  the  disease, 
and  result  commonly  from  contractures  of  muscles  which  are  less  para- 
lyzed than  others,  so  that  the  stronger  muscles  overcome  the  weaker. 
The  flexors  of  the  hands  are  commonly  affected,  and  these  members  are 
flexed  and  distorted,  the  fingers  being  drawn  up  so  that  their  ends  press 
into  the  palms,  as  is  the  case  in  other  forms  of  post-paralytic  contractures. 
The  arm  may  be  adducted  to  the  side,  and  forcible  abduction  or  extension 
is  impossible.  Pain  is  usually  produced  by  any  violent  effort  made  to  over- 
come the  deformity,  and  the  physician  is  obliged  to  desist.  The  patients 
are  able,  though  their  muscles  are  paralyzed  and  contracted,  to  perform 
certain  limited  movements,  but  the  same  tremor  takes  place  which  we 
observe  in  other  forms  of  sclerosis  when  a  voluntary  effort  of  any  kind  is 
made.  In  the  late  stages  the  emaciation  is  complete,  and  the  appearance 
of  the  hands  resembles  that  seen  in  progressive  muscular  atrophy.  There 
are  the  elevated  thenar  eminences  and  the  flat  forearms,  but  the  limb  is 
still  contracted.  Charcot  alludes  to  a  condition  which  sometimes  affects 
the  muscles  of  the  neck,  so  that  they  are  contracted  to  such  a  degree 
that  the  head  is  fixed  and  immovable.  He  relates  a  case  where  the  mus- 
cles of  the  interior  maxilla  were  so  contracted  as  to  greatly  interfere 
with  mastication. 

The  progress  of  the  disease  is  marked  by  involvement  of  the  tongue, 
and  later  by  destruction  of  the  nuclei  of  the  several  cranial  nerves,  so 
that  various  losses  of  special  function  rapidly  follow,  and  death  termi- 
nates the  patient's  sufferings.  The  inferior  extremities  are  paralyzed  in 
their  turn,  and  are  the  seat  of  contractures  which  resemble  in  some  re- 
spects those  of  the  upper  extremities,  so  that  the  patient's  condition  is  one 

1  I  prefer  this  compound  title,  as  it  obviates  confusion  and  more  definitely  ex- 
presses the  seat  of  the  disease. 
19 


290  DISEASES    OF    THE    SPINAL    CORD. 

of  helplessness.  The  legs  become  rigid  when  he  attempts  to  walk,  and 
are  agitated  by  tremors  so  that  he  is  obliged  to  desist.  The  contrac- 
tures  in  the  lower  extremities  are  much  more  marked  than  in  the  upprr, 
and  when  finally  the  victim  seeks  his  bed  he  presents  a  most  abject  and 
pitiable  appearance,  the  legs  being  twisted  and  contracted  so  that  he  re- 
quires the  services  of  an  attendant,  as  he  is  utterly  unable  to  do  anything 
for  himself.1  Fibrillary  tumors'  may  be  present  just  as  in  progressive 
muscular  atrophy,  but  are  not  so  constant  as  in  the  latter  disease.  The 
symptoms  which  usually  herald  the  approaching  end  of  the  disease  are 
those  which  indicate  invasion  of  the  bulb.  Paralysis  and  atrophy  of  the 
tongue,  vermicular  movements  of  that  organ,  and  affections  of  speech, 
are  among  these,  and  the  orbicularis  oris  and  facial  muscles  are  next 
attacked,  when  there  may  be  drooling  of  saliva  and  other  indications  of 
bulbar  degeneration.  In  short,  the  symptoms  are  very  much  like  thos<i 
of  bulbar  paralysis.  Sooner  or  later  the  pneumogastrics  are  implicated, 
and  death  follows.  The  disease  runs  its  course  in  from  six  months  to 
three  years. 

I  have  been  so  fortunate  as  to  see  one  case  of  this  disease,  the  notes  of 
which  I  append. 

E.  S.,  laborer.  About  one  year  ago  he  first  noticed  an  awkwardness  in 
holding  his  spade,  and  when  engaged  in  the  excavation  of  a  cellar  he  was 
unable  to  throw  up  the  dirt,  and  at  the  same  time  felt  unpleasant  formi- 
cations and  cramps.  These  became  so  distressing  that  he  applied  lini- 
ments to  his  wrist  and  arms,  but  without  any  relief  whatever.  He  con- 
sulted a  medical  man,  who  tried  electricity,  but  without  any  good  effect, 
and,  after  passing  two  or  three  months  without  treatment,  he  came  to  me, 
and  I  was  enabled  to  make  a  diagnosis  almost  immediately.  Both  hands 
were  strongly  flexed,  and  the  muscles  were  greatly  atrophied.  The  index 
finger  of  the  left  hand  alone  escaped  contraction.  There  was  some  rigid 
contraction  of  the  forearms,  while  the  arm  was  carried  upwards  and  for- 
wards by  the  muscles  of  the  shoulder  and  thorax,  and  there  was  no  move- 
ment at  the  elbow  or  wrist.  Fibrillary  contractions  were  observable  in 
the  triceps,  ]>ectoralis  major,  and  biceps.  When  I  endeavored  to  straighten 
the  arm  he  suffered  great  pain,  and  begged  me  to  desist.  There  seemed 
to  be  no  involvement  of  the  lower  extremities,  and  the  patient  walked 
without  embarrassment. 

Seeligmuller*  saw  several  curious  cases,  which  were  not  only  valuable  as 
instances  of  heredity,  but  which  illustrated  the  course  of  the  disease.8 

The  cases  came  under  the  observation  of  Seeligmuller  in  January,  1876. 
The  family  history,  which  was  carefully  inquired  into,  was  remarkably 
good,  with  one  significant  exception — that  the  parents  were  first  cousins. 
There  was  no  evidence  of  syphilis.  Seven  children — six  girls  and  one 
boy — were  the  result  of  the  marriage.  Of  these,  the  eldest,  aged  eleven, 

1  There  is  never  cutaneous  anesthesia,  the  bladder  and  rectum  are  never 
affected,  and  there  is  no  tendency  to  bedsores  (Charcot). 
*  Deutsche  Medicinischc  Woeli.,  April  22  and  29,  1876. 
8  London  Medical  Record,  Juue  15,  1876. 


ANTERO-LATERAL    AMYOTROPHIC    SCLEROSIS.  291 

was  quite  healthy ;  the  second,  aged  ten,  was  in  an  advanced  stage  of  the 
disease ;  the  third  was,  if  anything,  worse  still,  but  was  not  seen ;  the 
fourth,  a  boy,  aged  six  years  and  nine  months,  was  in  the  middle  stage ; 
the  fifth  and  sixth  were  healthy ;  and  the  seventh,  aged  one  year  and  nine 
months,  was  in  the  first  stage  of  the  affection.  The  disease  began  in  a 
similar  way  in  all.  Strong  and  healthy  when  born,  they  continued  so  up 
to  the  age  of  about  nine  months,  when  a  change  took  place.  Able  pre- 
viously to  sit  up  without  trouble,  they  began  to  lose  this  power,  and  would 
fall  to  one  or  other  side ;  later,  the  head  and  chest  sank  forward.  At  the 
ji.ire  of  two  years  attempts  were  made  to  teach  them  to  walk,  but  their 
efforts  resembled  those  of  an  infant  six  months  old.  This  was  exemplified 
in  the  youngest  patient,  who,  when  supported  under  the  armpits,  made 
jumping  movements,  the  legs  being  raised  from  the  ground  simultaneously. 
Subsequently  the  children  learned  to  support  themselves  with  difficulty 
against  a  chair,  but  even  this  power  was  lost  again.  The  boy  had  lately 
been  rapidly  losing  ground  in  this  respect;  he  could  still,  however,  drag 
himself  about  in  bed,  and,  by  means  of  a  specially  constructed  chair  on 
wheels,  could  walk.  The  two  eldest  children,  when  supported  in  the 
upright  position,  could  not  put  one  foot  before  the  other;  even  when  lying 
down,  they  were  unable  to  move,  the  upper  extremities  being  useless  as 
supports.  The  youngest  girl  could  sit  for  a  short  time  on  the  table,  but 
cried  all  the  time,  and  soon  fell  to  one  side ;  she  sat  with  her  head  and 
chest  inclined  forwards,  the  spine  equally  curved,  and  the  thighs  greatly 
abducted ;  when  on  the  lap,  however,  she  could  move  her  arms  and  legs  in 
all  directions. 

Contractions  at  the  joints  were  present  in  a  high  degree  in  the  three 
eldest.  In  the  eldest  girl  the  hands  were  adducted  and  pronated;  pain 
was  produced  by  attempts  at  passive  supination,  and  the  hand,  when  re- 
leased, jerked  back  to  its  old  position.  The  fingers  were  rolled  in  towards 
the  palm,  but  she  could  still  extend  them,  though  very  gradually  and  with 
great  difficulty.  The  grasp  was  still  perceptible;  the  right  better  than 
the  left.  The  elbows  were  slightly  bent,  and  nearly  fixed.  The  knees 
were  half  flexed,  but  could,  with  great  force,  be  moderately  extended  or 
flexed  still  more,  though  on  leaving  them  they  sprang  back  with  a  jerk. 
The  feet  were  in  the  position  of  advanced  equino-varus ;  the  tendines 
Achillis  were  perfectly  rigid.  All  attempts  at  passive  movement  produced 
considerable  pain.  The  boy  was  put  under  the  complete  influence  of 
chloroform,  and  the  rigidity  of  the  joints  then  so  increased  that  the  whole 
body  could  be  raised  from  one  leg  and  held  out  like  a  piece  of  wood.  The 
youngest  girl  had  so  far  no  contractions. 

Atrophy  of  the  muscles  was  marked  in  the  tAvo  eldest  under  observation. 
With  the  exception  of  those  of  the  face,  it  was  evenly  spread  over  the 
whole  system.  The  wasting  in  the  case  of  the  girl  was  considerable,  so 
that  the  head  seemed  too  large  for  the  attenuated  neck,  and  was  moreover 
unsteady.  The  parents  were  confident  that  in  all  three  the  wasting  was 
not  visible  for  some  time  after  the  loss  of  power  showed  itself. 

In  the  eldest  child  the  reaction  of  the  tibial  and  peroneal  nerves  was 
normal  with  both  currents ;  but  the  irritability  of  the  muscles  was  decidedly 
lowered  everywhere.  Of  those  on  the  back  of  the  forearm,  the  supinator 
longus  alone  responded  promptly.  In  the  youngest  girl,  faradic  excita- 
bility of  both  nerves  and  muscles  was  perceptibly  lowered  in  all  extremi- 
ties, but  especially  in  the  left  lower.  Galvanic  excitability  was  lowered 
in  the  same  way,  and  in  the  tibial  nerves  was  almost  nil.  Ordinary  reflex 


292 


DISEASES    OF    THE    SPINAL    CORD. 


irritability  not  increased.  That  of  the  tendons,  however,  was  present  in 
a  high  degree  in  all.  Fibrillary  contractions  were  markedly  present  in 
the  eldest  girl,  and  could  be  produced  by  simply  blowing  on  the  skin. 
Sensibility  was  normal  in  all. 

Of  the  symptoms  noticed  by  the  parents,  that  which  made  its  appear- 
ance last  was  the  gradual  loss  of  the  power  of  speech.  Thus,  in  the  two 
eldest  girls,  this  was  tolerable  until  their  sixth  year,  when  it  became  less 
and  less  distinct,  until  finally  only  inarticulate  nasal  noises  could  be  made. 
In  the  girl,  the  lips,  soft  palate,  and  uvula  were  all  paraly/ed,  and  the 
tongue  lay  in  the  mouth  like  a  mass  of  dead  flesh;  its  tip  could  be  ad- 
vanced only  as  far  as  the  teeth.  In  the  boy  the  same  symptoms  were 
present,  but  in  a  somewhat  less  degree.  The  youngest  child  could  say  a 
few  words,  but  these  had  a  slightly  nasal  tone.  Swallowing  in  the  two 
eldest  girls  was  difficult ;  in  the  boy,  tolerable.  The  form  of  the  skull  was 
unusual  in  all,  but  especially  so  in  the  eldest.  It  was  very  broad  between 
the  parietal  eminences,  and  very  undeveloped  in  the  frontal  region.  The 
forehead  was  low,  and  the  head  appeared  altogether  too  small  for  the  face. 
In  the  eldest  girl  the  features  were  coarse ;  the  expression  was  vacant, 
but  usually  amiable;  the  pupils  were  much  dilated;  the  saliva  flowed  con- 
tinuously out  of  the  half-opened  mouth  ;  and,  indeed,  her  general  appear- 
ance was  that  of  an  idiot;  though,  in  point  of  fact,  the  intellect  was  very 
fairly  developed.  The  faradic  excitability  of  the  facial  muscles  was  de- 
cidedly increased ;  the  galvanic  was  normal. 

Causes. — No  definite  causes  are  known,  though  exposure  is  believed 
to  have  much  to  do  with  its  origin,  and  Charcot's  and  Hammond's  cases  are 
thus  accounted  for  ;  but  we  may  also  consider  that  dissipation  and  hereditary 
influences  play  an  important  part  in  the  etiology  of  the  affection.  It  is  a 
disease  which  rarely  occurs  before  adult  life,  as  far  as  we  are  enabled  to 
judge  from  the  limited  number  of  cases  which  have  been  reported. 


Fig.  43. 


A.  Antcro-latcral  sclerosis.    B.  Posterior  spinal  sclerosis.     (After  Charcot.) 


Morbid  Anatomy  —  To  Charcot  belongs  the  credit  of  having  made  the 
distinction  between  progressive  muscular  atrophy  and  lateral  amyotrophic 
sclerosis.  Previous  to  18G7,  these  were  considered  to  be  cases  of  progres- 
sive atrophy,  which  were  anomalous  in  the  fact  that  the  lateral  columns 
were  affected.  Jaccoud1  considers  the  sclerosis  as  circumscribed  or  diffused 


1  Op.  cit.,  p.  319. 


LATERAL    SCLEROSIS    OF    THE    SPINAL    CORD.  293 

Like  sclerosis  in  other  regions,  the  tissue-changes  may  be  observed  with 
the  naked  eye,  either  invading  the  white  or  the  gray  matter  separately,  or 
more  often  together.  In  this  case  the  lesions  are  of  ancient  date.  The 
connective  tissue  is  firm  and  shrunken,  and  the  color  of  the  hardened  spot 
is  gray  or  pinkish-gray.  The  meninges  may  be  adherent  to  the  cord  if 
the  sclerosis  be  circumferential,  but  it  is  more  common  in  uncomplicated 
sclerosis  to  find  no  such  change.  The  microscopical  appearances  are  like 
those  seen  in  locomotor  ataxia,  as  the  character  of  the  lesion  is  identical, 
the  only  point  of  difference  being  the  location  of  the  tissue-change.  Cir- 
cumscribed sclerosis  is  more  rare  than  the  diffused  variety,  and  few  cases 
have  been  observed.  Of  examples  referred  to  by  Jaccoud,  in  one  the 
lesion  was  confined  to  the  lumbar  enlargement,  and  invaded  the  entire 
anterior  columns  and  a  part  of  the  lateral  columns ;  and  in  another,  in 
which  the  autopsy  was  made  by  Frommann,1  "the  sclerosis  occupied  the 
lumbar  segment  and  the  inferior  portion  of  the  dorsal  region.  It  involved 
in  different  degrees  all  the  white  matter,  and  the  gray  was  not  affected 
except  in  the  gelatinous  substance  and  in  the  parts  of  the  posterior  cor- 
nua  which  bounded  the  lateral  column."  The  sclerosis  has  involved  the 
entire  antero-lateral  columns,  the  anterior  columns  alone,  or  the  lateral  and 
the  lateral  and  posterior  conjointly.  In  diffused  sclerosis,  nodules  are  found 
in  various  parts  of  the  brain  and  cord,  but  the  predominance  of  the  sclerosis 
in  the  antero-lateral  column  gives  prominence  to  the  symptoms  which  I 
have  described. 

Diagnosis It  is  possible  that  this  disease  may  be  confounded  with 

either  progressive  muscular  atrophy,  lateral  sclerosis,  or  spinal  para- 
lysis. In  the  first  we  find  a  train  of  symptoms  consisting  of  neuralgic 
pains,  atrophy  of  single  muscles  or  groups,  and  involvement  of  other 
muscles  progressively,  and  secondary  paralysis.  There  are  besides  no 
spasmodic  contractions.  In  lateral  sclerosis  there  is  no  atrophy  beyond 
that  resulting  from  inaction.  In  the  disease  known  as  spinal  paralysis 
the  lower  extremities  are  generally  affected  first,  and  reflex  excitability 
and  electric  irritability  are  diminished,  which  is  not  the  case  in  the  disease 
which  has  just  been  described. 

Prognosis — Hopeless. 

Treatment I  think  it  may  be  said  that  no  treatment  offers  any 

chance  of  success,  though  in  the  early  stages  Duchenne  claims  to  have  cured 
several  cases  by  means  of  faradization,  massage,  and  other  forms  of  local 
treatment. 

LATERAL  SCLEROSIS  OF  THE  SPINAL  CORD. 

Synonym Primary  symmetrical  lateral  sclerosis. 

Symptoms Paralysis  of  an  incomplete  character  without  atrophy, 

and  with  subsequent  contractures,  is  the  marked  feature  of  the  malady. 
Like  most  other  diseases  of  this  nature,  a  loss  of  power  is  complained  of 

1  Anatomie  des  Riickenmarks,  Jena,  1864. 


294  DISEASES    OF    THE    SPINAL    CORD. 

in  the  beginning.  The  patient  is  easily  fatigued,  and  it  becomes  disagree- 
able for  him  to  take  the  least  exercise  whatever,  on  account  of  the  wearied 
feeling  of  the  muscles  of  the  leg  and  thigh  which  results.  The  hamstring 
muscles  tire  the  soonest,  and  it  fatigues  him  excessively  to  remain  for  any 
length  of  time  in  the  erect  position.  The  knees  after  a  while  become 
bent,  and  the  lower  extremities  may  grow  rigid,  while  the  tendines 
Achillis  may  perhaps  be  contracted  so  that  there  may  be  a  species  of 
talipes.  Contracturcs  of  the  adductors  may  take  place  to  such  a  degree 
that  the  thighs  are  drawn  across  each  other  so  that  locomotion  after  a 
while  is  impossible.  Hammond  lias  reported  a  case  of  this  kind.  The 
walk  of  the  patient  is  decidedly  peculiar,  as  he  is  unable  to  lift  his  feet 
from  the  ground  to  any  extent,  and  he  consequently  stumbles  and  finds 
great  difficulty  in  progression.  Hammond  thus  describes  the  gait :  "  Owing 
to  the  fact  that  the  patient's  extensor  muscles  are  weak,  he  is  unable  to 
lift  the  feet  high  enough  to  cause  them  to  clear  the  ground,  and  hence  he 
throws  them  out  by  means  of  the  adductor  muscles  of  the  thigh,  and  thus 
causes  them  to  describe  an  arc  of  a  circle.  Then  in  putting  them  down 
the  heel  strikes  the  ground  a  longer  time  before  the  sole  than  it  does  in 
the  natural  gait,  and  hence  the  foot  comes  down  with  a  jerking  motion. 
This  is  the  ordinary  manner  of  walking  practised  by  a  person  afflicted 
with  the  disease  under  notice.  In  another  form  of  locomotion  the  body  is 
moved  laterally  on  the  thighs,  first  to  one  side  and  then  to  the  other,  in 
such  a  way  as  to  cause  the  feet  to  be  raised  high  enough  without  the  com-  ' 
plete  action  of  the  extensor  muscles.  The  gait  is  therefore  similar  to  that 
of  a  duck,  or  of  a  woman  with  a  very  wide  pelvis.  The  motion  of  the 
body  is  almost  serpentine,  and  the  feet  glide  over  the  ground  barely  lifted 
high  enough  to  avoid  contact."1  Sensibility  is  rarely  affected,  and  reflex 
excitability  is  as  much  exaggerated  as  it  is  in  other  forms  of  sclerosis,  for 
instance  in  locomotor  ataxia.  The  disease  runs  its  course  in  ten  or  fifteen 
years,  and  death  is  the  ordinary  result,  though  several  cases  have  been 
reported  ;is  cured. 

Morbid  Anatomy — The  limitation  of  the  sclerosis  to  the  lateral 
columns  is  nearly  always  well  defined.     The  sclerosis  is  symmetrical,  and 

Fiji.  44. 


A,  A.— Lateral  sclerosed  patches.     (Chareot.) 


confined  to  the  white  matter,  bounded  in  front  by  the  external  angles 
of  the  anterior  horns,  and  behind  by  the  anterior  border  of  the  posterior 
horns.  It  may  extend  centrifngally  to  the  circumference  of  the  cord,  but 
is  more  often,  according  to  Chareot,  shut  off  by  a  tract  of  white  matter. 

1  Diseases  of  the  Nervous  System,  p.  569. 


TETANUS.  295 

Diagnosis — Locomotor  ataxia,  lateral  amyotrophic  sclerosis,  and 
spinal  meningitis  may  be  said  to  be  the  disorders  with  which  it  may  pos- 
sibly be  confounded.  The  presence  of  contractures  enables  us  to  dispose 
of  the  first  affection,  and  the  absence  of  atrophy  and  bulbar  symptoms  the 
second.  Occasionally  the  diagnosis  will  be  more  difficult,  and  this  is 
when  chronic  spinal  meningitis  exists  alone,  or  when  the  lateral  sclerosis 
is  found  to  be  a  result  of  such  meningitis,  as  sometimes  happens. 

Treatment. — Hammond  recommends  large  doses  of  ergot  in  the 
early  stages.  I  see  no  reason  why  the  same  remedies  spoken  of  in  the 
treatment  of  locomotor  ataxia  should  not  be  administered.  Conium  sug- 
gests itself  as  a  physiological  remedy  for  the  relief  of  the  spasmodic  con- 
tractions, but,  not  having  used  it,  I  am  unable  to  attest  its  value. 


TETANUS. 

Synonyms — Rigor  nervosus ;  Mai  de  cerf ;  Tetanos  (Fr.) ;  Locked 
jaw. 

Definition. — Tetanus  is  an  affection  characterized  by  tonic  spasms  of 
a  great  number  of  muscles,  particularly  those  of  the  jaw,  neck,  back,  and 
lower  extremities.  It  is  never  attended  by  loss  of  consciousness,  and 
nearly  always  approaches  an  unfavorable  termination.  It  is  a  disease 
which  may  be  either  idiopathic  or  traumatic,  and  is  not  confined  to  any 
age  or  sex,  as  it  may  be  a  condition  at  birth  (trismus  nascentium),  or 
occur  at  any  subsequent  time. 

Symptoms — The  more  familiar  examples  follow  traumatism,  and 
such  injuries  may  be  exceedingly  slight — the  wound  of  a  rusty  nail,  a 
needle,  or  a  blunt  instrument  being  often  likely  to  give  rise  to  the  attack ; 
or  it  may  be  of  distinctly  idiopathic  origin.  The  first  symptoms  generally 
noticed  are  a  stiffness  of  the  neck,  a  slight  soreness  of  the  throat,  and  a 
contraction  of  the  jaws  so  that  it  may  be  difficult  for  the  patient  to  open 
his  mouth.  There  may  be  general  malaise  and  discomfort,  which  may 
last  for  several  days,  and  the  patient  is  unable  to  masticate  or  swallow  his 
food  properly,  and  consequently  eats  but  little.  He  may  think  that  he 
has  simply  caught  cold,  and  neglect  to  seek  medical  advice;  but  new 
developments  will  show  the  condition  to  be  more  serious  than  he  imagines. 

The  closure  of  the  jaw  may  become  more  complete,  and  within  the  next 
twenty-four  hours  (the  fourth  or  fifth  day  of  the  affection)  he  will  show 
unmistakable  signs  of  the  increasing  violence  of  the  disease.  His  face 
wears  the  peculiar  expression  which  has  been  called  the  risiis  sardonicus, 
the  features  appearing  pinched  and  set,  and  the  corners  of  the  mouth  are 
drawn  upwards,  while  the  eyes  are  prominent  and  the  hair  and  eye- 
brows quite  bristling.  The  brows  are  knit,  and  there  is  a  characteristic 
appearance,  which,  if  once  seen,  cannot  be  mistaken.  Radcliffe  considers 
the  risus  sardonicus  quite  pathognomonic  of  tetanus.  Pain  in  the  epigas- 
trium becomes  very  severe,  and  is  not  relieved  by  medicine.  It  is  impos- 
sible sometimes  to  open  the  jaws  even  when  we  desire  to  give  food  or 


296  DISEASES    OF    THE    SPINAL    CORD. 

medicine,  and  it  is  sometimes  necessary  to  use  quills  and  other  delicate 
tubes  for  the  purpose  of  feeding.  Spasms  of  the  pharyngeal  muscles  may 
also  defeat  all  attempts  of  this  kind,  for,  even  if  the  teeth  are  parted  and 
nourishment  is  inserted,  the  food  is  forced  with  great  violence  through  the 
nostrils.  Other  spasms  now  mark  the  progress  of  the  disease.  The 
muscles  of  the  back  begin  to  be  convulsed,  and  finally  those  of  the 
lower  extremities,  and  as  a  consequence  we  observe  the  appearance  of 
opisthotonos,  which  is  an  extremely  striking  symptom,  and  much  more 
common  than  emprosthotonos,  which  may  also  take  place,  orpleurosthotonos. 
It  is  hardly  necessary  to  say  that  opisthotonos  is  the  result  of  a  tonic  spasm 
of  the  muscles  of  the  back,  so  that  the  patient's  body  describes  an  arc,  the 
head  and  heels  touching  the  surface  upon  which  he  is  lying,  and  the  middle 
of  the  back  being  raised  some  distance  therefrom.  When  the  body  is  bent 
in  the  opposite  direction — forwards — the  condition  is  known  as  empros- 
thotonos; and  when  the  muscles  upon  one  side  of  the  body  are  contracted 
we  designate  the  lateral  curve  produced  as  pleurosthotonos.  During  this 
tonic  convulsive  state  individual  muscles  may  be  the  seat  of  painful  spasms, 
which  are  very  agonizing.  Muscles  have  been  torn  across  and  bones 
broken  by  the  great  strain,  and  the  force  exerted  is  something  wonderful. 
The  tongue  is  rarely  affected,  and  the  hands  are  not  usually  at  any  time 
rigid  or  contracted.  The  spasms  are  easily  produced  by  slight  agen- 
cies, as  reflex  irritability  is  decidedly  exaggerated.  Jarring  the  bed, 
tickling  of  the  soles,  or  a  draught  of  air  allowed  to  blow  upon  the  surface 
will  immediately  bring  them  on.  This  convulsive  stage  lasts  until  death, 
but  when  the  end  is  approaching  becomes  less  sthenic  as  the  patient  grows 
more  and  more  exhausted.  There  may  be  an  occasional  severe  paroxysm 
before  death,  but  it  is  not  at  all  like  the  form  of  violent  convulsion  of  the 
middle  stages.  The  pulse  throughout  the  developed  disease  is  very  rapid 
and  fluttering,  and  ranges  between  120  and  140, and  the  respiratory  move- 
ments are  irregular  and  catching,  as  the  spasms  affect  the  muscles  of  the 
thorax  as  well  as  others  which  are  directly  concerned  in  this  process. 
Dyspnoea  is  very  distressing,  and  is  expressed  between  the  seizures  by  much 
gasping  and  anxiety  of  countenance.  The  skin  is  dark,  and  large  rings 
about  the  eyes  are  indicative  of  collapse  while  the  face  of  the  victim  is 
haggard  and  depressed.  The  patient  perspires  quite  profusely,  and  the 
skin  is  excessively  hot;  and  a  prominent  feature  of  tetanus  is  the  marked 
elevation  of  temperature,  which  rises  even  sometimes  as  high  as  110°, 
and  actually  reaches,  a  higher  point  after  death.  In  a  case  observed  by 
Wunderlich1  there  was  a  marvellous  elevation  of  this  kind,  and  a  very 
tardy  fall  after  death. 

1  Archiv  dcr  Ileilkunde,  Bd.  ii.,  iii.,  and  v.  (18G1-G3).    Reported  by  Radcliffe. 


TETANUS 


29T 


Date. 

Respiration. 

Pulse. 

Temperature 
(Fahrenheit). 

24th  July,  1861 
25th 
26th                         9 
"                          6 
"                          9. 
"                          9. 
af 

A.M. 
P.M. 
20  P. 
35  P. 
ter  de 

M.       ! 
M.,  death,    . 
ith,     2' 
5' 
20' 
35' 
55' 
60' 
70' 
90' 
100' 
6  hours 
9     " 
12     " 
13£  " 

24 
22 

20 
32 
36 

96 
82 
96 
112 
180 

102° 
102 
104.45 
103.55 
110.1 
112.55 
112.77 
113 
113.22 
113.55 
113.67 
113.55 
113.22 
113 
111.8 
106.25 
104 
102 
101 

ft.. 

Dr.  Joseph  Jones,  of  New  Orleans,  the  author  of  one  of  the  most  able 
articles  upon  this  subject  that  has  ever  appeared,  has  made  numerous  exami- 
nations of  the  urine.  He  found  that  the  quantity  of  urine  excreted  during 
the  "active  stages  was  greatly  diminished  from  the  normal  standard,  and 
in  the  successful  cases  treated  the  amount  increased  with  subsidence  of  the 
symptoms."  He  also  found  that  the  urea  was  increased  during  the  active 
stages,  and  the  uric  acid  was  diminished. 

The  diminution  of  the  excretion  of  urine  is  by  him  supposed  to  be 
accounted  for  by  the  small  quantity  of  fluids  taken,  and  by  the  loss  of  liquid 
in  profuse  perspiration. 

The  mind  is  perfectly  clear  throughout  the  disease,  and  the  patient  suf- 
fers great  mental  misery  as  he  fully  realizes  his  terrible  condition ;  and 
sleep  is  nearly  always  absent,  this  being  one  of  the  most  distressing  fea- 
tures of  the  disease.  If  this  is  obtained,  even  in  brief  snatches,  the  mus- 
cles are  relaxed,  and  all  spasms  disappear  for  the  time,  but  immediately 
reappear  upon  awaking.  The  probable  cause  of  death  is  either  the 
closure  of  the  glottis,  or  exhaustion,  which  is  an  inevitable  result  of  the 
violent  muscular  action.  In  new-born  children  the  disease  sometimes 
appears  between  the  first  and  fifth  days,  the  first  symptoms  noted  being 
restlessness,  trembling  of  the  lower  jaw,  and  desire  for  the  breast,  which 
the  child  leaves  almost  immediately.  At  the  end  of  twenty-four  hours,  or 
even  earlier,  the  muscles  of  the  jaw  are  felt  to  be  contracted  and  rigid, 
and  it  cannot  open  its  mouth;  there  is  a  peculiarly  aged  expression 
upon  its  face,  the  skin  of  the  forehead  being  wrinkled.  The  eyelids  are 
closed,  and  the  lips  are  compressed  over  the  teeth.  The  head  is  drawn 
back,  and  general  spasms  of  the  muscles  of  the  back  follow.  Periods  of 
remission  occur,  and  the  patient  is  thrown  into  a  paroxysm  by  the  most 


298 


DISEASES    OF    THE    SPINAL    CORD. 


trivial  agencies.  The  skin  is  very  red  and  dark,  and  after  a  series  of 
paroxysms,  which  may  continue  for  several  days,  death  closes  the  scene. 

Causes. — Exposure  to  damp  and  cold  are  the  only  known  exciting 
causes  of  the  idiopathic  variety;  and  traumatisms  of  certain  kinds,  or 
accidents  during  parturition,  precede  the  other  form.  A  punctured  wound, 
which  may  be  received  from  a  nail  or  splinter,  is  much  more  likely  to 
give  rise  to  tetanus  than  an  incised  wound  ;  and  injuries  in  which  there 
is  mangling  or  crushing  of  muscular  tissue  are  frequently  concerned  in 
the  production  of  the  disease.  Railroad  injuries  are  therefore  especially 
dangerous.  Tetanus  sometimes  follows  surgical  operations,  and  it  has  been 
thought  in  these  cases  to  depend  upon  partial  section  of  some  nerve-trunk. 
Dupuytren1  goes  far  enough  to  recommend  re-amputation.  It  may  be 
stated  that  in  certain  regions  there  are  apparent  endemic  influences  at  the 
time  of  such  predisposition,  when  any  surgical  operation  may  have  this 
termination.  This  local  influence  prevails  in  Cuba  and  other  tropical 
countries,  and  in  Long  Island  and  in  other  parts  of  the  American  sea- 
board. 

Jones  has  collected  the  statistics  of  tetanus,  and  the  following  table 
shows  its  prevalence  in  hot  climates  : — 


Place. 

Period. 

Total  deaths. 

Deaths  from 
tetanus. 

Proportion. 

London 
Ireland 
Now  York 
Bombay     . 

1850-3-4 
1831-1851 
1819-1834 
1851-1853 

224,515 
1,187,374 
83,783 
42,651 

73 
238 
112 
912 

1  in  3075 
1  in  4987 
1  in  748 
1  in  46 

I  am  indebted  to  Dr.  Charles  Findlay,  of  Havana,  Cuba,  for  the 
following  concise  table,  which  shows  the  prevalence  of  the  disease  in  that 
island  : — 


Logons  Oralt-s,  tome  ii.  pp.  599-612. 


TETANUS. 


299 


1872. 

1873. 

1874. 

1875. 

1876. 

Average. 

ni 

00 

•j- 

00 

m 

00 

i. 

CO 

• 

00 

00 

• 

d 

d 

d 

d 

d 

Z 

d 

3 

a 

3 

<2 

<£ 

3 

3 

<2 

3 

(OS 

2 

d 

- 

d 

2 

d 

tj 

d 

2 

d 

d 

3 

January, 

4 

47 

4 

39 

34 

4 

33 

G 

17 

4.2 

34.0 

Pop.  of  Havana, 

250,000. 

February, 

5 

29 

1 

30 

3 

18 

4 

30 

4 

30 

3.4 

27.4 

Births  per  annum, 

5000. 

March, 

6 

24 

3 

28 

4 

31    5 

24 

4 

29 

4.4 

27.2 

Deaths  by  tetanus  in. 

April, 

6 

26 

5 

30 

0 

24    4 

18 

5 

26 

4.0 

24.8 

Adults  =  0.192  a  year 

per  1  000  inhabitants. 

Mav. 

3 

27 

1 

29 

3 

33    5 

30 

3 

35 

3.0 

30.8 

June, 

2 

24 

3 

33 

2 

36 

5 

29 

5 

39 

3.4 

32.2 

Deaths  of  infantile 

tetanus. 

July, 

4 

25 

5 

20 

4 

31 

3 

36 

3 

35 

3.8 

29.4 

7£  per  hundred  births. 

August, 

3 

35 

5 

33 

5 

45    5 

38 

2 

46 

4.0 

37.4 

September, 

3 

28 

1 

29 

3 

41    3 

42 

6 

33 

3.2 

34.6 

October, 

1 

42 

6 

32 

3 

36    1 

43 

4 

37 

3.0 

38.0 

November, 

6 

45 

4 

42 

4 

29    3 

37 

6 

41 

4.6 

38.8 

December, 

2 

36 

4 

23 

4 

31    5 

28 

7 

40 

4.3 

31.6 

12  months, 

45 

388 

42 

368 

38 

389 

47 

388 

55 

408 

48.4 

382.2 

Yearly  average. 

4.0 

31.8 

Monthly  average. 

Long  Island,  it  seems,  has  gained  an  unenviable  notoriety  as  a  place 
where  tetanus  is  exceedingly  common  ;  but  it  will  be  seen  that  there  is 
much  exaggeration  in  the  reports  which,  as  a  rule,  come  to  us  in  the 
newspapers,  and  which  are  nearly  always  sensational.  During  the  past 
year  I  have  devoted  some  time  to  the  investigation  of  the  subject,  have 
written  to  several  well-known  physicians  of  eastern  Long  Island,  and 
have  received  two  or  three  letters  in  reply. 

Dr.  Stilwell,  an  old  settler  of  Sag  Harbor,  whose  opportunities  for 
research  have  been  quite  extensive,  writes  as  follows:  "About  20  years 
ago  I  came  to  this  place  to  practise,  and  learning  the  fact  of  the  preva- 
lence of  tetanus,  or  its  liability  from  certain  accidents,  I  attempted  an  in- 
vestigation, but  failed  of  any  success  or  satisfaction.  Several  supposed 
cases  having  recovered  naturally  brought  many  cases  under  my  observation, 
but  most  of  them  died.  Several  did  not,  and  from  my  after-remarks  here 
you  will  perceive  the  reason.  I  have  never  known  the  disease  to  exist  as 
an  epidemic,  but  it  is  apt,  at  certain  seasons  of  the  year,  to  follow  wounds. 
Hot  and  damp  weather,  with  cool  evenings,  is  its  favorite  season."  The 
Doctor  has  known  but  two  instances  of  recovery  from  traumatic  tetanus. 

When  a  patient  has  recovered  from  tetanus  it  has  been  by  a  very  slow 
process,  the  period  between  the  spasms  lengthening  until  they  finally  dis- 
appeared. Under  favorable  circumstances  this  required  several  weeks. 
"  I  have  known  fatal  cases  of  idiopathic  tetanus  in  July  and  August  caused 
by  fatigue  and  overheating,  and  sitting  down  to  cool  off  in  the  ocean 
breezes.  Farmers  have  often  informed  me  that  the  white  frost  on  grass 


300  DISEASES   OF    THE    SPINAL    CORD. 

would  give  cattle  lockjaw.  I  have  known  a  horse  driven  to  fatigue  turned 
out  to  pasture  in  a  cool  night  when  white  frost  formed  upon  the  grass,  and 
die  with  tetanus.  I  have  known  horses,  in  the  heat  of  summer  driven  seven 
miles  to  the  seashore  and  there  cooled  off  in  the  ocean  breezes,  die  of  the 
same  disease.  The  multiplicity  of  cases  occur  in  summer  and  in  the  heated 
term  with  cool  nights.  A  farmer  bruised  his  thumb-nail  and  pulled  tur- 
nips in  a  frosted  field ;  he  died  of  tetanus."  The  other  letters  I  have  received 
are  in  substance  very  much  like  that  of  Dr.  Stilwell,  and  none  of  them 
suggest  that  the  disease  is  as  frequent  as  it  is  generally  supposed  to  be. 
Dr.  Benjamin,  of  Riverhead,  says  :  "  I  have  practised  thirty  years  in  this 
village,  have  an  average  of  about  one  case  each  year  (others  claim  twice 
that  number),  and  should  think  the  other  physicians  in  the  Assembly  Dis- 
trict would  average  about  the  same;  if  so,  it  would  make  nineteen  cases 
each  year  with  a  population  of  19,000.  My  opinion  is  that  there  has  been 
no  marked  change  in  the  past  forty  years  as  to  its  frequency  or  fatality. 
A  very  large  proportion  of  our  cases  prove  fatal  in  from  one  to  three 
days.  Of  trismus  nascentium  I  have  had  six  cases  during  the  past  thirty 
years,  all  of  which  were  fatal."  The  information  that  I  have  derived 
from  popular  sources  is,  however,  somewhat  contradictory.  I  learn  that 
about  Good  Ground,  which  is  nearly  twenty  miles  west  of  Sag  Harbor, 
there  are  times  when  traumatic  tetanus  is  very  common ;  and  it  is  not  safe 
for  any  person  who  has  received  even  the  most  trivial  injury  to  remain  in 
the  neighborhood. 

Capt.  Foster  and  Capt.  Joseph  Penny,  of  Ponquogue,  which  is  upon  the 
sea-coast,  state  that  they  have  known  of  tetanus,  which  was  very  common 
at  certain  seasons ;  several  of  their  friends  have  died,  and  others  have 
moved  tem|M>rarily  from  the  place  as  soon  as  injured.  It  was  not  uncom- 
mon for  women  about  to  be  confined  to  leave  the  locality ;  and  cases  ot 
trismus  neonatorum  were  of  quite  frequent  occurrence.  One  man  whose 
foot  had  been  crushed  by  a  horse  died  in  a  few  days. 

From  Mr.  Wells,  of  Quogue,  I  ascertained  that  the  disease  is  con- 
fined almost  entirely  to  the  district  extending  from  Moriches  to  East 
Hampton,  and  that  at  the  extreme  easterly  end  of  the  Island  (Mon- 
tauk  Point)  no  case  has  been  known  to  occur.  So  perfect  is  the  immu- 
nity at  this  place,  that  colts  are  taken  there  to  be  castrated  and  not 
removed  until  the  wound  is  healed.  The  disease  is  more  common  during 
the  fall  than  at  any  other  season.  Mr.  Wells  has  known  of  from  twenty 
to  twenty-five  cases,  mostly  men  and  boys,  in  a  district  forty  miles  long, 
during  the  past  five  years.  In  this  region  castrated  colts  generally  die 
soon  after  the  operation.  In  one  case,  of  which  my  informant  knew,  a 
man  was  shooting  ducks  in  a  battery  ;  his  shot-gun  accidentally  went  off, 
the  charge  removing  about  one-half  of  the  great  toe.  The  wound  was  not 
especially  painful,  but  at  the  end  of  eight  days  convulsions  began,  and  he 
died  in  thirty-six  hours. 

Mr.  White,  of  South  Hampton,  scratched  his  thumb  with  a  brier  in  the 
field,  and  afterwards  died.  Mr.  Hand,  of  Canoe  Place,  died  after  a  slight 


TETANUS. 


301 


injury  to  the  ankle.  Mr.  Wells  also  told  me  that  several  cases  followed 
wounds  received  in  the  field  where  a  form  of  shellfish  known  as  the  "horse 
shoe"  (king  crab)  is  used  for  manure.  By  the  fall  these  craw-fish  have 
undergone  advanced  decomposition,  and  their  long  spines,  which  project 
in  any  direction,  are  very  apt  to  wound  the  bare-footed  field  hand.  These 
statements  are  entitled  to  some  credence,  for  the  Doctor  was  very  often 
not  called  in.  At  the  eastern  end  of  the  island  several  cases  of  fatal  teta- 
nus within  a  very  short  time  occurred  in  the  practice  of  Dr.  Trudeau,  then 
of  Little  Neck.  Along  the  Atlantic  sea-board  I  am  told  that  this  disease 
is  by  no  means  uncommon,  and  that  on  the  Southern  sea-coast  it  is  much 
more  frequently  met  with  than  in  higher  latitudes.  In  a  very  interesting 
communication  from  Dr.  Findlay,  of  Havana,  he  mentions  a  case  in  which 
the  application  of  a  blister  in  a  case  of  pleurisy  was  followed  by  fatal 
tetanus.  The  accompanying  map  will  enable  the  reader  to  perceive  the 
geographical  distribution  of  endemic  tetanus  on  Long  Island,  the  dark  spots 
showing  the  limit  of  the  region,  and  the  points  where  it  prevails  to  the 
reatest  extent. 


Fig.  45. 


/S      20 


so  miles  1o  /  mc7i/f 
LONG    ISLAND     SOUND 


MAP  OF  SUFFOLK  COUNTY,  LONO  ISLAND.— 1.  Manor.  2.  Riverhead.  3.  Sag  Harbor.  4.  East 
Hampton.  5.  South  Hampton.  6.  Ponquogue  and  Good  Ground.  7.  Quogue.  8.  West  Hampton. 
9.  East  Moriches.  10.  Centre  Moriches.  11.  Seatuck.  12.  Greenport.  13.  Montauk  Point.  14. 
Bridge  Hampton.  Darkest  spots  indicate  points  of  greatest  prevalence. 

Cold  climates  have  something  to  do  with  the  production  of  tetanus,  aa 
we  would  infer  from  Dr.  Kane's  statement  that  intense  cold  produced  "an 
anomalous  spasmodic  affection  allied  to  tetanus,"  which  affected  most  of  his 
party,  destroyed  two  men,  and  killed  all  his  dogs.  Trismus  neonatorum 
is  supposed  by  Vogel1  to  depend  upon  the  formation  of  the  cicatrix  when 
the  cord  is  roughly  handled,  and  there  is  probably  pressure  of  some  nerve 
by  the  contraction  of  the  cicatrix. 

1  Diseases  of  Children,  p.  65.     Translation  by  Raphael,  N.  Y.,  1870. 


302  DISEASES    OF    THE    SPINAL    CORD. 

Frost-bite  may  sometimes  give  rise  to  tetanus,  and  the  following  cases 
are  examples  of  this  kind: — 

They  occurred  under  the  care  of  Dr.  Bethune,  of  Toronto.  The  first 
was  that  of  a  farmer  who  was  exposed  to  intense  cold  for  about  three 
hours  while  driving.  His  feet  and  fingers  became  severely  frost-bitten 
without  his  becoming  aware  of  the  fact  until  he  arrived  home.  On  admis- 
sion to  the  Toronto  General  Hospital,  four  days  later,  the  toes  and  the 
greater  part  of  both  feet  were  found  in  a  condition  of  moist  gangrene. 

The  fingers  and  parts  of  both  hands  on  the  dorsal  surface  were  black 
and  dry.  Four  days  after  admission  he  was  seized  with  tetanic  symptoms, 
which  rapidly  developed.  Chloral  hydrate  in  thirty-grain  doses,  with 
extract  of  Calabar  bean  in  one-fourth-grain  hypodermic  doses,  until  five 
grains  had  been  given,  failed  to  combat  the  disease,  and  the  patient  died 
in  thirty  hours  after  the  accession  of  the  attack. 

The  second  case  was  that  of  a  man  who,  having  lain  out  in  a  barn  all 
night,  had  both  feet  severely  frost-bitten,  subsequently  becoming  partially 
gangrenous.  In  this  case  trismus  set  in  nine  days  after  exposure,  and 
soon  developed  into  well-marked  tetanus,  to  which  the  patient  succumbed 
in  about  thirty  hours.1 

Morbid  Anatomy  and  Pathology — The  older  writers  have 
written  a  great  deal  in  regard  to  the  morbid  anatomy  o't'  tetanus,  but  the 
collected  facts  throw  no  light  upon  the  pathology,  and  are  to  a  great  degree 
valueless. 

Lockhart  Clarke1  in  18G5  found  in  six  cases  that  there  was  degeneration 
of  the  gray  substance  of  the  cord.  "  The  first  case  was  reported  at  some 
length,  and  the  lesion  was  found  more  or  less  from  the  origin  of  the  second 
cervical  nerves  to  the  lumbar  enlargement.  At  the  second  cervical  nerve, 
streaks  and  irregular  areas  of  disintegration  were  observed  in  different 
parts  of  the  gray  substance,  and  particularly  around  the  central  canal,  on 
the  right  side  of  which  was  a  space  of  considerable  size  containing  a  finely 
granular  fluid,  with  the  debris  of  bloodvessels  and  nerves.  The  posterior 
and  lateral  white  columns,  especially  along  the  edge  of  the  various  fissures 
which  transmit  bloodvessels,  were  damaged  in  a  similar  way,  and  in  some 
sections  the  deeper  portions  of  the  posterior  columns  which  rest  upon  the 
transverse  commissure  were  softened  to  a  considerable  degree.  This  dis- 
integration was  still  more  marked  in  the  cervical  enlargement,  chiefly  be- 
hind and  at  the  sides  of  the  canal.  The  posterior  commissure  was  wholly 
and  the  anterior  partially  destroyed  by  a  fluid  transparent  and  granular 
area.  Throughout  the  cervical  enlargement  similar  lesions  were  dis- 
covered, varying  from  a  state  of  softening  to  one  of  complete  solution,  and 
diminishing  at  intervals  or  almost  disappearing,  to  return  shortly  in  the 
same  form.  At  the  upper  part  of  the  dorsal  region  the  shape  of  the  cord 
was  much  altered,  and  extensive  lesions  of  the  same  kind  were  everywhere 
seen.  In  both  lateral  halves  of  the  gray  substance,  the  left  lateral  col- 
umns, the  right  antero-lateral  column,  the  superficial  portion  of  the  ante- 

1  London  Lancet,  March,  1875. 

*  Mcd.-Chir.  Trans.,  1848  and  1365,  and  Mcd.  Times  and  Gazette,  1805. 


TETANUS.  303 

rior  columns,  and  in  the  posterior  columns,  similar  appearances  were 
found.  Below  this  point  there  was  less  disease  as  far  as  the  fourth  dorsal 
vertebra.  Here,  in  addition  to  the  areas  of  disintegration,  large  extrava- 
sations of  blood  were  found  along  the  whole  lateral  part  of  the  gray  sub- 
stance on  both  sides  of  some  sections,  in  one  side  only  of  others ;  while  the 
lumbar  region  manifested  the  same  lesions  as  the  cervical." 

Dr.  James  Tyson1  has  detailed  two  cases  in  which  softening  of  the  pos- 
terior columns  occurred.  In  one  of  these  there  was  extravasation  of  blood 
in  the  posterior  columns,  and  to  some  extent  from  the  vessels  of  the  pia 
mater.  The  central  gray  commissure  was  destroyed.  In  the  other  case 
no  extravasation  was  found  in  the  posterior  columns,  but  there  was  venous 
congestion  of  the  dura  mater.  I  was  presented  by  Prof.  L.  McLane 
Tiffany,  of  Baltimore,  with  a  piece  of  the  cord  of  one  of  his  patients  who 
had  died  with  tetanus  following  a  severe  burn.  The  pia  mater  was  greatly 
thickened,  and  the  small  posterior  arteries  were  enlarged.  Throughout 
the  section,  which  was  viewed  at  first  with  a  low  power  objective,  I  per- 
ceived a  rather  extensive  increase  of  the  neuroglia.  The  anterior  nerve- 
roots  appeared  to  be  very  well  defined.  Throughout  the  white  and  gray 
matter  there  were  visible  numerous  round  cells  quite  translucent  and 
bright,  which  resembled  somewhat  colloid  bodies.  These  were  more 
plentiful  in  the  posterior  column.  The  vessels  of  the  gray  matter  were  all 
more  or  less  enlarged,  and  some  of  them  were  surrounded  by  spaces  which 
were  considerably  wider  than  the  diameter  of  the  vessel.  The  cells  of  the 
anterior  cornua  were  quite  disintegrated,  and  some  had  taken  an  oval  form. 
Those  that  could  be  recognized  were  found  to  have  broken  processes,  and 
many  had  granular  contents.  The  nerve-trunks  were  unaffected. 

Arlong3  and  Tripier,  Erichsen,  and  Bouillaud  found  that  the  end  of 
the  nerve  in  the  wound  was  diseased,  and  Lepelletier3  and  Froriep*  dis- 
covered in  one  case  that  the  neurilemma  of  the  nerves  in  the  vicinity  was 
the  seat  of  inflammatory  changes,  which  extended  from  the  periphery  to 
the  cord.  This  latter  appearance  indicates  an  exceptional  condition  of 
affairs,  and  as  for  the  nerve-change  in  the  wound,  it  is  not  to  be  won- 
dered at,  for  if  there  is  any  importance  to  be  attached  to  the  circumstance 
of  the  morbid  appearance  of  an  injured  nerve,  it  is  certainly  inconsidera- 
ble, when  we  consider  how  frequent  must  be  such  a  pathological  condition, 
and  still  there  is  not  a  proportionate  amount  of  tetanus. 

Our  knowledge  of  the  pathology  of  tetanus  is  based  almost  entirely  upon 
the  experiments  of  physiologists,  and  we  are  left  somewhat  in  the  dark  as 
to  the  questions  :  1.  Whether  it  is  a  central  disease  resulting  from  a  mor- 
bid peripheral  irritation  which  is  reflected  upon  the  cord.  2.  Whether  it 
is  a  central  disease  per  se,  and  the  appearances  noted  after  death  are  pri- 
mary. 3.  Whether  the  morbid  changes  are  secondary  to  the  symptoms, 
and  due  to  mechanical  causes. 

We  have  so  far  been   taught  how  general  spasm  may  be  produced. 

1  The  Practitioner,  Aug.  1877.  *  Archives  de  Physiol.,  1870. 

3  Revue  Medicale,  iv.,  1827.  4  Neue  Notizen,  1837. 


304  DISEASES    OF    THE    SPINAL    CORD. 

Mitchell1  and  Morehouse  caused  in  animals  very  violent  convulsions 
by  injecting  into  the  vertebral  canal  a  half  ounce  of  fluid,  and  very  hot  or 
very  cold  water  seemed  to  aggravate  the  spasms.  Cold  applied  to  the 
spine,  whether  produced  by  the  rhigoline  spray  or  by  ice,  gave  rise  to 
the  same  phenomena.  Cold  to  the  medulla  caused  the  animal  to  topple 
backwards. 

Upon  examination  the  vessels  were  found  to  be  intensely  congested. 
So  far,  we  are  furnished  with  the  first  link  in  our  chain.  Assuming  that 
the  spasmodic  movements  are  due  to  a  congestion  of  the  cord,  and  con- 
ceding that  pathological  anatomy  has  furnished  us  in  nearly  every  instance 
with  evidence  of  congestion  of  the  gray  matter,  we  are  to  discover  what 
is  the  factor  of  such  congestion.  It  may  depend  upon  a  reflected  im- 
pression transmitted  to  the  vaso-dilators,  or  it  may  depend  upon  local 
irritation  by  impure  blood  which  produces  secondary  hypenemia.  In 
strychnine  poisoning,  the  symptoms  of  which  resemble  those  of  tetanus 
very  closely,  the  spasmodic  phenomena  are  undoubtedly  due  to  the  im- 
perfect oxygenation  of  the  blood  ;  consequently  the  cord  is  supplied  with 
blood  loaded  with  carbonic  oxide.  It  seems  to  me  very  possible  that 
the  same  condition  of  affairs  exists  in  tetanus ;  that  there  may  be  direct 
irritation  of  the  nervous  matter  of  the  cord  dependent  upon  some  primary 
blood  condition. 

Fox*  very  clearly  expresses  himself  as  follows :  "  The  abnormal  blood 
imperfectly  nourishes  the  cord.  An  imperfectly  nourished  cord  is  ipso 
facto  an  excitable,  an  impressible  cord;  this  impressibility  renders  arterial 
spasms  abnormally  facile,  whether  the  exciting  cause  is  the  circulation  in 
the  cord  of  more  of  the  morbid  blood,  or  reflected  irritation  from  a  diseased 
nerve  at  the  periphery,  or  reflex  irritation  from  any  other  cause  and  from 
any  other  point  in  the  body,  and  if  this  arterial  contraction  goes  on  for 
any  protracted  period,  or  is  frequently  repeated,  we  may  find  various 
lesions  due  to  imperfect  blood-supply  in  addition  to  those  due  to  dimin- 
ished nutrition  from  the  original  nature  of  the  blood,  while,  as  a  sequence 
of  the  spasmodic  arterial  contractions,  we  get  hyperaemia  and  perhaps 
exudation,  and  lastly  the  pressure  of  the  exudation  or  some  peculiarity 
in  its  nature  may  lead  to  some  disintegration  of  the  nervous  centres." 

This  theory  seems  to  me  to  be  tenable  for  several  reasons:  1.  Injuries 
of  peripheral  nerves  are  common,  and  the  cases  of  resulting  tetanus  are  out 
of  all  pro|K)rtion  to  those  presenting  no  subsequent  nervous  symptoms.  2. 
Its  endemic  nature,  its  prevalence  in  certain  districts,  and  its  not  uncom- 
mon idiopathic  origin  when  there  is  no  ascertained  eccentric  cause.  3. 
The  appearances  of  the  cord  are  of  a  destructive  character,  and  it  is  a 
matter  of  doubt  whether  they  are  not  more  a  result  than  a  cause. 

Considerable  discussion  has  taken  place  in  regard  to  the  cause  of  the 
high  elevation  of  temperature.  Verneuil  does  not  consider  it  due  either  to 
myelitis  of  the  superior  part  of  the  cord,  or  to  asphyxia  or  muscular  con- 

1   Am.  Journ.  Med.  Sciences,  1866.  *  Op  cit.,  p.  362. 


TETANUS.  305 

tractions ;  but  Huron  is  decidedly  of  the  opinion  that  such  increase  in 
temperature  is  alone  the  result  of  muscular  action.  Mason  has  experi- 
mented, and  found  that  the  temperature  of  a  tetanized  muscle  is  often 
increased  from  one  to  two  degrees. 

The  medulla  has  been  found  in  more  than  one  instance  to  be  the  seat  of 
grave  lesions,  and  it  is  probable  that  the  trismus  and  other  evidences  of 
an  excited  state  of  cranial  nerve  innervation,  which  occur  in  the  begin- 
ning, are  indications  of  primary  disturbances  in  the  bulb. 

Diagnosis — The  diseases  with  which  tetanus  may  be  confounded  are 
hydrophobia,  strychnine  poisoning,  hysteria,  and  acute  spinal  meningitis. 
In  the  first  there  is  no  risus  sardonicus ;  the  convulsions  are  clonic ;  there 
is  the  noisy  hawking  and  effort  to  spit ;  the  dread  of  water,  the  delirium, 
and  finally  the  history  of  a  bite  by  a  rabid  animal,  which,  however,  is  not 
always  to  be  ascertained.  Strychnine  poisoning  is  very  easily  mistaken 
for  tetanus.  In  poisoning  by  a  large  dose  of  the  alkaloid  the  symptoms 
appear  rapidly,  and  death  takes  place  in  a  short  time.  The  hands 
are  clenched  and  rigid,  but  the  jaw  can  be  opened,  which  is  not  possible 
in  tetanus.  This  resemblance  between  the  two  conditions  has  been  made 
use  of  in  more  than  one  poisoning  case  as  a  ground  of  defence,  and  in  that 
of  Cooke,  who  was  poisoned  by  Palmer,  the  question  was  narrowed  down 
to  the  appearance  of  the  cord.  Cases  of  hysteria  sometimes  present  symp- 
toms which  not  rarely  counterfeit  those  of  tetanus.  The  jaw  may  be 
locked,  but  there  will  be  few  of  the  other  features.  Hysterical  patients 
are  nearly  always  seemingly  unconscious,  and  there  are  no  evidences  of 
suffering  whatever.  In  spinal  meningitis  the  muscular  rigidity  seems  to 
be  dependent,  in  a  great  measure,  upon  the  patient's  effort*  to  relieve  the 
pain  which  is  produced  by  an  uncomfortable  position.  The  locked  jaw, 
which  is  an  early  symptom  of  tetanus,  is  absent  in  acute  spinal  meningitis. 

Prognosis — Dr.  Jones1  has  collected  480  cases  of  tetanus,  213  of 
which  recovered  under  treatment,  the  mortality  being  49.2  per  cent.,  or 
one  death  in  2.02.  These  were  all  cases  of  traumatic  tetanus.  The  per- 
centage of  death  in  the  British  army  during  the  Crimean  War  was  91  per 
cent. ;  and  Baron  Larrey's  estimate  of  mortality  of  the  French  army  under 
Napoleon  was  at  about  the  same  rate. 

In  regard  to  the  time  of  death  Dr.  Jones  found  that  of  50  cases,  in  which 
the  disease  followed  slight  injury  of  the  extremities,  43  proved  fatal  in  a 
short  time,  and  of  the  whole  number  of  deaths  reported  24.14  per  cent,  ran 
a  rapid  course  after  slight  injuries,  and  terminated  in  death  in  a  few  days. 
One  case  died  on  the  second  day.  Cases  are  reported  which  have  termi- 
nated fatally  in  twenty -four  hours  after  the  appearance  of  symptoms.  In 
one  case,  mentioned  by  Dazelle,  they  appeared  on  the  third  day,  and  the 
patient  died  the  same  night.  Hammond  lays  stress  upon  the  statement 
that  the  prognosis  is  governed  by  the  interval  that  elapses  between  the 
receipt,  of  the  wound  and  the  appearance  of  the  symptoms,  and  that  the 
longer  this  interval  is  the  more  favorable  are  the  patient's  chances.  Many 

1  Medical  and  Surgical  Memoirs,  vol.  i.,  Xew  Orleans,  1§76. 
20 


306  DISEASES    OF    THE    SPINAL    CORD. 

writers  agree  that  elevated  temperature  playa  an  important  part  in  the 
prognosis,  and  that  any  increase  is  to  be  looked  upon  with  alarm.  The 
duration  of  the  attack  is  to  be  taken  into  account,  and  every  day  bridged 
over  by  the  patient  after  the  fourth  or  fifth  increases  his  chances  of 
recovery.  Of  course  the  gravity  of  the  affection  depends  much  upon  the 
violence  of  the  paroxysms. 

Treatment It  would  be  useless  to  discuss  the  merits  of  the  many 

drugs  that  have  been  brought  forward  from  time  to  time.  Our  most  clli- 
cacious  remedial  agents  are  the  depresso-motors,  and  among  these  may  be 
mentioned  chloroform,  chloral  hydrate,  Indian  hemp,  Calabar  bean,  and 
conium  (FF.  56,  39,  3,  4,  82,  51). 

Calabar  bean,  which  has  enjoyed  a  deserved  popularity,  has  been  inside 
use  of  with  great  success  by  Eilert,  Holhouse,  Wood,  Watson,  and  a  host 
of  others.  Holhouse  in  1864  reported  two  cases,  one  of  which  was 'cured 
after  having  taken  3-4^  grains  of  the  extract  every  two  hours.  Ashdown  wus 
not  so  successful,  and  Spencer  and  Dickenson  had  the  same  discouraging 
experience.  Even  Watson  was  one  of  the  first  to  use  the  remedy,  and 
three  out  of  his  four  cases  of  tetanus  were  cured  by  the  administration  of 
ten  drops  of  the  tincture  every  hour,  and  by  a  subsequent  increase  in  the 
dose.  The  drug  may  be  given  in  full  doses,  say  from  one-quarter  to  one- 
third  of  a  grain  of  the  extract  every  two  hours. 

The  chloral  treatment  has  certainly  been  more  efficacious.  Surgeon- 
Major  Hunter1  reported  two  cases  :  one  a  boy,  and  the  other  a  man  of  40. 
In  the  first  case  chloral  was  combined  with  cannabis  indica.  R.  Tr. 
cannabis  ind.  n^x;  potass,  bromid.  gr.  v,  every  third  morning;  and  chloral 
hydrat.  gr.  xij,  three  times  a  day,  together  with  inhalations  of  chloroform 
as  required.  The  other  patient  took  20  grains  of  the  chloral  thriee 
daily.  Opium  and  chloral  in  combination  have  perhaps  been  more  effec- 
tive than  the  chloral  alone,  and  Del  sal*  saved  three  cases  out  of  four  by 
this  treatment.  II.  C.  Wood  reports  9  cures  out  of  18  cases  by  chloral. 

Chloroform  has  not  proved  to  be  the  valuable  remedy  that  many  have 
supposed  it  to  be,  and  it  has  only  the  power  to  "crowd  down  the  bad 
symptoms  which  burst  forth  usually  with  additional  fury  when  the  narcosis 
subsides." 

Aconite  has  been  of  service  upon  many  occasions.  It  was  first  used  by 
Page8  in  a  case  of  traumatic  tetanus.  The  toxic  effects  of  the  dnig  were 
produced,  and  during  their  continuance  there  was  a  remission  of  symp- 
toms. The  patient  was  first  reduced  to  a  condition  bordering  on  syncope, 
and  afterwards  stimulated.  De  Morgan  and  others  cured  tetanus  with 
this  remedy,  and  its  place  in  the  therapeutics  of  the  affection  is  by  no 
means  an  inferior  one. 

The  pulse  is  markedly  lowered,  the  muscular  rigidity  relaxed,  and  a 
condition  of  akinesis  and  prostration  takes  the  place  of  the  irritable  ner- 

1  Indian  Med.  Gaz.,  Feb.  ],  1875. 

2  Quoted  in  Practitioner,  August,  1877. 
*  Lamrvt,  April  4,  1846. 


TETANUS.  307 

vous  state.  Curare,  nitrite  of  amyl,  and  belladonna,  as  well  as  a  host  of 
remedies  of  the  same  character,  have  been  praised  from  time  to  time, 
but  most  of  them  are  useless.  Chloral  hydrate,  either  in  combination 
with  aconite,  or  chloroform,  and  cold  to  the  spine,  which  may  be  ap- 
plied by  the  ether  spray  as  recommended  by  Carpenter,  I  think  is  the 
best  form  of  treatment,  and  should  be  resorted  to  as  early  as  possible.  If 
these  remedies  fail,  Calabar  bean,  curare,  or  nitrite  of  amyl  may  be  tried, 
and  conium,  which  is  a  powerful  depressor  of  spinal  excitability,  may  be 
given  a  trial.  Warm  baths  have  been  recommended. 

"  Dr.  F.  Franzolini1  relates  a  case  of  tetanus  arising  from  exposure  by 
sleeping  on  the  damp  ground  after  great  fatigue  successfully  treated  by 
prolonged  warm  baths  and  the  continual  use  of  chloral  and  morphia.  The 
chloral  was  given  frequently  by  the  stomach,  and  the  morphia  by  subcuta- 
neous injection.  The  first  bath  was  for  six  hours,  at  a  temperature  of  40° 
C.  (104°  F.),  and  subsequent  ones  lasted  five,  four,  three,  or  two  hours. 
This  treatment  was  carried  out  from  the  18th  to  the  30th  of  the  month; 
but  the  daily  use  of  chloral  and  morphia  was  continued  some  time  longer. 
Of  the  first  ninety  hours  of  his  disease,  the  patient  passed  forty -eight  in 
the  bath  at  40°  C.  In  twenty-nine  days  he  consumed  nearly  four  ounces 
of  chloral  hydrate,  and  about  twenty-two  grains  of  hydrochlorate  of  mor- 
phia were  injected.  Although  kept  so  long  in  a  state  of  almost  constant 
narcotism,  the  mental  powers  of  the  patient  were  in  no  way  affected." 

H.  de  Renzi,2  of  Genoa,  has  spoken  highly  of  the  dark-room  treatment. 
His  patient  was  kept  absolutely  quiet.  He  ascribes  the  success  to  the 
belief  that  the  absorption  of  oxygen  and  elimination  of  carbonic  oxide  are 
impeded  by  darkness. 

The  other  indications  seemed  to  be  perfect  quiet,  and  during  and  after 
the  attack  ample  nourishment.  Niemeyer3  believes  in  clysters  containing 
twenty  or  thirty  drops  of  laudanum.  He  also  recommends  chamomile  baths 
in  the  infantile  variety. 

1  The  Doctor,  Oct.  1,  1875.     Abs.  in  Phila.  Med.  Times,  Oct.  30,  1875. 

2  Gaz.  M6d.  do  Paris,  No.  32,  1877. 

3  Text-Book  of  Pract.  Med.,  vol.  ii.  p.  352. 


308  BULBAR    DISEASES. 


CHAPTER    XII. 

BULBAR  DISEASES. 

EPILEPSY. 

Synonyms — L'Epilepsie  (Fr.);  Fallsucht  (Ger.);  Mai  caduco(ItaL). 

Definition — This  most  familiar  of  all  nervous  diseases  is  characterized 
by  loss  of  consciousness  of  variable  duration,  attended  or  unattended  by 
either  slight  muscular  spasms  or  general  convulsions. 

The  relation  of  these  two  elements,  the  psychical  and  physical,  is  not 
always  the  same,  as  in  some  forms  of  the  disease  there  is  a  momentary  loss 
of  consciousness  .and  perhaps  no  appreciable  spasm,  or  the  two  may  coexist, 
there  being  protracted  loss  of  consciousness  and  violent  convulsions. 
There  are  sometimes  very  peculiar  combinations  of  symptoms  which  will 
receive  mention  hereafter. 

The  scope  of  this  work  does  not  permit  me  to  consider  the  history  of  the 
disease  ;  suffice  it  to  say  that  its  antiquity  dates  back  to  the  days  of  Hip- 
pocrates and  Aretteus,  and  biblical  references  to  its  existence  are  common. 

Cooke1  thus  speaks  of  the  early  writings  :  "  Epilepsy  has  been  distin- 
guished by  a  great  variety  of  names  such  as  morbus  sacer,  comitialis  her- 
culcns,  caducua,  etc.  Aretaeus  says,  it  may  have  been  called  sacred  on 
account  of  the  magnitude  of  the  evil,  it  being  customary  to  call  what  is 
great  by  that  name  ;  or  because  it  is  to  be  cured  rather  by  the  Divine  than 
by  human  power,  or  because  persons  laboring  under  it  have  been  thought 

possessed  by  demons.7 Some  of  the  ancients  were  of 

opinion  that  epilepsy  was  denominated  the  Herculean  disease  because 
Hercules  was  subject  to  it ;  but  Galen  says  it  was  so  called  on  account  of 
its  form  or  magnitude." 

"  Epilepsy  was  denominated  morbus  comitialis,  either  because  it  fre- 
quently occurred  in  the  crowded  assemblies  of  the  Romans  called  comitia, 
in  which  the  passions  of  the  people  were  often  much  excited,  by  which  it 
might  be  occasioned,  or  because  it  was  customary  to  dissolve  the  comitia 
if  during  the  sitting  any  person  should  be  affected  by  it. 

"  The  application  of  the  term  caducus,  a  falling  sickness,  is  too  evident  to 
need  illustration." 

In  our  description  of  the  affection  it  is  impossible  to  make  any  well- 
defined  division  ;  suffice  it  to  say  that  all  writers  recognize  forms  known 
as  Hant  mal  or  Epilepsia  gravior,  and  Petit  mal  or  Epilepsia  mitior. 
Reynolds  divides  the  latter  into  two  varieties,  viz. :  1st.  A  form  with  evi- 

1  Treatise  on  Nervous  Diseases,  Am.  ed.  1824,  p.  326. 
1  Aret.  de  Caus.  ct  Sign.  Morb.,  lib.  i.  c.  4. 


EPILEPSY.  309 

dent  spasms,  and  another  without  evident  spasms.  Besides  these,  various 
irregular  forms  have  been  included,  such  as  masked  epilepsy  and  hystero- 
epilepsy. 

THE  GRAVE  ATTACK. 

Symptoms — The  most  familiar  variety  is  known  asJSpilepsia  gravior, 
and  it  may  be  described  as  an  attack  expressed  in  four  stages :  1st.  A 
premonitory  stage ;  2d.  Stage  of  convulsion ;  3d.  Stage  of  subsidence ; 
and  4th.  A  stage  of  stupor,  or  "after-stage"  (Reynolds).  The  first  stage 
may  often  be  absent,  for  in  many  cases  there  is  a  sudden  debut ;  but  if 
such  be  not  the  case,  the  patient  may  have  well  recognized  warnings  which 
may  be  either  psychical  (mental  or  emotional),  motorial,  sensorial,  or 
vascular,  these  latter  being  objective  indications.  Though  these  warnings 
are  spoken  of  by  many  patients,  it  is  almost  impossible  to  rely  upon  their 
testimony,  as  the  demoralization  dependent  upon  the  anticipation  of  the 
attack,  or  the  short  duration  of  such  premonitory  symptoms,  is  sufficient  to 
prevent  them  from  analyzing  their  feelings.  It  is,  however,  possible  in 
many  instances  to  collect  information  from  a  number  of  cases  which  shall 
be  a  basis  for  the  general  classification  of  premonitory  symptoms. 

Very  often  the  attack  will  be  immediately  preceded  by  a  vague  dread, 
or  an  undefined  fear  of  some  impending  trouble. 

In  one  of  my  cases — a  remarkably  clever  and  intelligent  young  lady — 
there  is  a  condition  of  exhilaration  of  spirits,  and  a  mental  activity  which 
lasts  for  some  hours.  Although  deeply  under  the  influence  of  the  bromide, 
she  will  come  out  of  her  apathetic  state  and  chat  with  her  friends  upon  all 
subjects  in  the  most  entertaining  manner.  Twitching  of  the  eyelids  or  of 
the  lower  extremities,  vertigo  with  rotatory  movement,  and  tremor  are 
examples  of  the  disorders  of  motility  which  occasionally  precede  the 
attack.  Sometimes  there  is  an  elevated  sensitiveness  of  the  organs  of 
special  sense. 

Hallucinations  of  hearing,  or  visual  hallucinations,  are  not  uncommon. 
One  of  my  patients  has  often  seen  a  fiery  cross ;  and  another  refers  to  a 
locomotive  with  a  glaring  headlight,  which  rushes  upon  him ;  while  a 
third  hears  voices ;  and  in  two  cases  the  patients  say  that  they  "  smell 
smoke."  Morbid  sensations,  which  cannot  be  defined,  are  spoken  of  oc- 
casionally, and  a  vague  sense  of  weight  in  the  epigastrium,  head,  or  some 
other  part  of  the  body  is  a  frequent  precursor  of  the  attack.  Occasionally 
the  peculiar  sensations  begin  at  some  remote  part  of  the  body,  and  seem 
to  move  rapidly  towards  the  head ;  such  phenomena  are  known  as  aurce. 
These  aura  have  been  compared  to  the  blowing  of  wind  over  the  surface, 
the  creeping  of  insects  upon  the  skin,  or  the  pricking  of  needles.  They 
last  but  for  a  few  seconds,  and  are  sometimes  perceived,  but  not  always. 
In  the  wards  under  my  charge  at  the  Epileptic  Hospital,  the  patients 
sometimes  have  perceived  the  aurce  in  time  to  seek  the  nurse  or  to  attract 
the  notice  of  the  other  patients.  Careful  investigation  of  twenty-nine 
cases  resulted  in  the  discovery  that  eighteen  of  them  had  a  warning  of 


310  BULBAR    DISEASES. 

some  kind,  four  had  none,  and  the  rest  gave  us  unsatisfactory  answers. 
After  a  long  process  of  condensation  of  statements,  I  find  that  seven  had 
an  aura  starting  from  the  epigastric  region,  two  complained  of  constriction 
of  the  chest,  seven  had  slight  vertigo,  and  one  had  an  aura  starting 
from  the  extremities,  and  in  one  there  was  trembling  of  the  right  hand. 
Headache  preceded  the  attack  in  four,  and  the  "  indescribable  feeling"  of 
the  coming  fit  was  alluded  to  by  a  number.  In  one  remarkable  case  the 
first  intimation  of  the  attack  was  the  violent  jerldng  of  the  head  to  one 
side,  and  a  species  of  vertigo.  In  another  case  the  patient  muttered  in- 
coherently for  a  full  minute  before  the  actual  attack.  A  third  case  was 
equally  curious.  The  patient,  whose  mental  condition  was  good,  would, 
without  any  apparent  reason,  attract  the  attention  of  persons  about  him  by 
the  repetition  of  the  syllables  "  be-lub-be-lub,  be-lub,  lub,  lub-a-luh,  a-lub," 
pitching  his  voice  in  a  high  key,  and  gradually  lowering  the  tone  until  the 
last  part  of  his  utterance  was  hushed  and  low,  and  then,  after  giving  vent 
to  a  species  of  groan,  he  would  become  convulsed.  Trousseau1  calls  at- 
tention to  the  "  vascular  prodromata."  A  local  determination  of  blood 
may  occur  in  the  finger,  for  instance,  causing  it  to  swell,  reddening  the 
skin,  and  rendering  it  successively,  within  a  very  short  time,  red,  and  of 
a  more  or  less  deep  violet  color ;  or,  again,  the  skin  may  become  exces- 
sively pale  after  having  been  injected  for  some  time.  The  swelling  is 
real,  not  apparent ;  for  rings  previously  easy  suddenly  become  too  tight 
for  the  finger.  The  only  premonitory  symptom  may  sometimes  be  an 
involuntary  discharge  of  urine.  It  is  difficult  to  distinguish  this  accident, 
however,  and  it  is  very  liable  to  be  considered  a  part  of  the  attack,  which 
it  may  be  in  reality. 

2d  Stage  (Stage  of  Convulsion) — In  many  cases  the  first  indication  of 
the  attack  is  a  wild  cry,  which  startles  those  about  the  patient.  I 
have  seen  a  soldier  marching  in  procession  throw  up  his  gun  and  shriek 
so  loud  as  to  be  heard  half  a  block  away,  and  fall  to  the  pavement  in  a 
convulsion.  This  shriek  is  a  psychical  manifestation,  and  different  from 
another  form  of  cry  which  the  patient  may  utter.  This  second  variety  is 
less  noisy,  and  is  produced  by  the  forcible  expulsion  of  air  through  the  vocal 
cords  which  follows  spasm  of  the  thoracic  muscles.  It  is  more  a  species 
of  groan.  Simultaneously  there  is  loss  of  consciousness,  and  the  patient 
falls  to  the  ground,  and  is  agitated  by  tonic  contraction  of  all  the  muscles 
of  the  body,  but  usually  those  of  one  side  more  than  the  other;  so  that  his 
body  is  twisted  and  bent.  The  muscles  of  the  neck  are  strongly  con- 
tracted, while  the  face  is  generally  distorted.  The  stronger  contraction 
if  some  muscles  than  others  draws  the  weaker  side  so  that  movements  are 
produced  which  are  not  the  result  of  clonic  contraction,  but  rather  an  evi- 
dence of  unequally  expended  forces.9  Respiration  stops,  or  there  may  be 
a  long  expiration,  and  then  stoppage  al together  for  a  few  seconds.  The 
pulse  is  now  rapid  and  very  small,  a  result,  probably,  of  compression  of 
the  arteries  by  muscular  masses,  and  the  heart-beats  are  strong.  At  the 


1  Cliuicul  Medicine,  Am.  e<K,  vol.  i.  p.  75.  2  Reynolds. 


EPILEPSY.  311 

end  of  a  few  seconds,  and  rarely  after  a  minute,  the  convulsions  become 
clonic,  the  patient  throwing  his  arms  about  violently,  or  bumping  the  back 
of  his  head  upon  the  floor.  He  is  still  unconscious,  and  may  have  evacua- 
tions from  his  bowels  and  bladder,  or,  as  in  some  of  the  cases  that  I  have 
seen,  there  may  be  an  emission  of  semen.  Reynolds  calls  attention  to  vom- 
iting, a  symptom  which  I  have  several  times  witnessed.  The  respiration 
now  becomes  labored  and  rapid,  and  there  may  be  snoring.  Froth  col- 
lects about  the  mouth,  which  may  be  tinged  with  blood,  as  the  patient 
sometimes  bites  his  tongue  or  lips.  The  surface,  which  was  in  the  first 
stage  quite  pale  and  cool,  now  becomes  dusky,  and  of  a  dark  livid  color. 
The  pupils  may  remain  dilated  as  they  were  at  the  onset  of  the  attack,  or 
may  be  unequal.  From  my  note-book  I  find  that  the  following  points 
were  observed  in  the  twenty-nine  cases  previously  alluded  to.  In  twenty- 
six  the  convulsions  were  quite  general.  In  three  the  legs  were  more  con- 
vulsed than  any  other  part.  In  three  the  arms  were  especially  agitated. 
In  one  patient  the  movements  were  confined  to  the  left  side.  The  cry 
was  very  piercing  in  five  instances.  In  three  there  was  only  a  moan  or 
gurgling  expiratory  sound.  Twenty-four  of  these  patients  bit  their 
tongues.  In  twenty-three  the  pupils  were  widely  dilated.  In  two  the 
dilation  was  not  so  marked.  In  four  no  appreciable  difference  was  no- 
ticed. After  the  stage  of  tonic  convulsion,  which  lasts  a  few  minutes,  the 
third  stage  is  reached. 

3d  Stage  (Stage  of  Subsidence) — This  is  marked  by  a  gradual  re- 
turn of  consciousness.  The  patient  may  stupidly  turn  his  head  or  look 
upwards,  the  eyes  having  a  meaningless  expression,  and  the  balls  oscillat- 
ing slightly.  He  may  strive  to  express  himself,  but  only  gives  utterance 
to  a  series  of  unintelligible  sounds.  He  may  make  some  effort  to  rise, 
but  finds  it  impossible  to  do  so.  His  pulse  is  small  and  thready,  or  some- 
times full  and  bounding,  especially  when  the  first  two  stages  have  been 
short.  His  eyes  are  injected,  and  his  pupils  either  normal  or  contracted. 

4th  Stage  (Stage  of  Stupor) — Exhausted  by  his  attack,  he  falls  into 
a  sound  sleep,  which  is  so  profound  that  he  lies  where  he  has  fallen,  and 
resents  any  attempt  to  remove  him.  The  stupor  may  be  so  deep, 
however,  as  to  make  him  unmindful  of  what  is  going  on  about  him.  His 
sleep  lasts  for  several  hours,  and  is  characterized  by  snoring.  If  the 
patient  recovers  without  the  stupor,  he  is  very  irritable  and  cross.  He 
complains  of  headache,  or  perhaps  nausea,  and  vomits ;  and  his  pulse  is 
irritable  and  irregular.  Thompson1  calls  attention  to  the  tracings  ob- 
tained in  epilepsy  when  the  heart  is  healthy,  and  it  is  possible  to  obtain 
good  results.  He  as  well  as  Lorain  found  that  the  sphymograph  tracing 
exhibited  a  distinct  dicrotic  notch. 

In  regard  to  the  time  of  attack,  two  divisions  have  been  made — noctur- 
nal and  diurnal.  I  have  thought  it  best  to  make  another,  viz. :  ma- 
tutinal. 

Perhaps  nocturnal  epilepsy  is  much  more  common  than  the  other  forms, 

1  West  Riding  Reports,  vol.  ii.  p.  303. 


312  BULBAB    DISEASES. 

for  n  greftt  many  patients  never  have  attacks  at  any  other  time,  while  some 
may  have  them  at  all  times,  and  a  few  only  (luring  the  day.  A  large  number 
are  attacked  just  as  they  awaken  ;  and  I  have  met  this  form  so  frequently 
that  I  prefer  to  use  the  term  matutinal  for  the  attacks  occurring 
between  five  and  nine  in  the  morning.  The  only  sign  of  a  nocturnal 
attack  may  be  the  evidence  of  involuntary  passages  of  urine  and  feces, 
and  sometimes  both.  Blood  upon  the  bed  linen  as  a  consequence  of 
tongue-biting  is  another  indication,  and  the  trouble  which  is  required  to 
rouse  the  patient  is  a  third.  Of  forty-eight  patients,  fourteen  had  their 
attacks  at  irregular  hours,  seventeen  had  their  attacks  at  night  only,  five 
in  the  day,  and  twelve  in  the  morning. 

Dr.  Maury,  of  Memphis,  has  communicated  to  me  the  following  two 
cases  of  dislocation  of  the  bones  during  an  epileptic  paroxysm.  This  is  a 
rare  accident  in  epilepsy,  although  it  is  more  common  in  tetanus. 

CASE  I.  A  man  from  Holly  Springs,  Miss.,  was  sent  to  Dr.  M.  in  Dec. 
1876.  The  patient  was  sixty  years  of  age,  a  planter,  and  of  good  habits. 
About  one  year  before,  after  eating  his  supper,  he  became  ill  and  had 
convulsions.  In  the  night  he  had  fresh  convulsions,  and  suffered  consid- 
erably from  pain  in  the  right  shoulder.  The  convulsions  recurred  at  in- 
tervals of  ten  days.  When  he  was  brought  to  Dr.  M.  the  shoulder  was 
found  to  be  shrunken,  and  the  humerus  dislocated  and  immovable. 

CASK  II.  A  lady  from  Alabama,  during  the  menopause,  was  affected 
with  epilepsy  about  two  years  and  a  half  before  the  Doctor  saw  her. 
She  was  attacked  at  night  with  convulsions  and  pain  in  left  hip.  These 
attacks  occurred  at  intervals  of  from  two  to  four  weeks  before  she  was 
seen  by  a  physician.  Left  lower  extremity  found  to  be  shortened  about 
two  inches,  femur  evidently  dislocated.  Muscular  contraction  on  outside 
of  leg  ;  toes  everted,  and  thigh  turned  inwards.  In  this  case  no  attempt 
was  made  to  reduce  the  dislocation.  Whenever  she  had  convulsions  there 
was  pain  in  region  of  liver. 

THE  LIGHT  ATTACK. 

Symptoms — The  lighter  forms  of  epilepsy  are  included  under  the 
head  of  Epilepsia,  mitior,  and  are  attended  by  a  very  transitory  loss  of 
consciousness.  There  may  be  little  or  absolutely  no  spasm,  and  the  attack 
may  be  so  unpronounced  as  to  escape  the  notice  of  those  persons  who  may 
happen  to  be  present.  The  patient  may  be  eating  at  the  time,  and  suddenly 
drops  his  knife  and  fork  ;  or  he  may  be  engaged  in  some  occupation,  and 
suspends  operations  for  a  second.  In  one  of  my  patients  the  only  indica- 
tion of  the  attack  was  the  rolling  upwards  of  the  eyes.  Another,  a  gentle- 
man, when  writing  would  stop  for  a  moment  and  go  on  with  his  work 
entirely  unconscious  of  any  interruption.  If  walking,  there  may  be  a 
sudden  loss  of  equilibrium,  but  he  rarely  falls.  The  face  may  be  blanched 
or  flushed  momentarily,  and  the  patient  may  suffer  no  bodily  discomfort, 
but  is  sometimes  restless,  depressed,  or  low-spirited. 

A  more  aggravated  state  may  exist,  in  which  the  muscular  spasms  are 
more  marked. 

The  attacks,  which  have  been  described  as  "  weak  spells,"  or  "fainting 


EPILEPSY.  313 

fits,"  by  uninformed  people,  consist  in  more  protracted  loss  of  conscious- 
ness, accompanied  perhaps  by  strong  muscular  contractions  of  the  muscles 
of  the  face  or  arms,  pallor,  and  dilatation  of  the  pupils.  I  have  a  patient 
under  observation  who  has  a  distinct  epigastric  aura;  she  then  becomes 
rigid,  holds  her  breath,  grasps  the  arms  of  her  chair ;  her  head  is  drawn 
forwards,  and  so  she  remains  for  a  minute  or  two. 

The  foregoing  forms  may  coexist,  there  being  distinct  attacks  of  grand 
mal,  with  repeated  petit  mal  seizures,  which  seem  to  have  no  special  rela- 
tion to  the  more  serious  convulsions.  Twelve  of  the  twenty-nine  cases 
suffered  from  grandma!  alone,  and  seventeen  had  both  forms,  and  in  these 
cases  the  petit  mal  predominated. 

As  to  periodicity  and  frequency 'of  the  attacks  there  is  much  to  be  said. 
There  is  a  peculiarity  in  the  regularity  of  the  seizures  which  is  to  be 
observed  in  very  many  cases.  «A  tendency  to  weekly,  semi-monthly,  or 
monthly  recurrence  is  noticed. 

When  the  fits  take  place  there  may  be  only  one  at  a  time,  or  there  may 
be  a  number  within  twenty-four  hours  or  two  or  three  days,  and  then  an 
interval  of  the  duration  I  have  just  described  elapses  before  a  fresh  attack 
or  series  of  attacks  takes  place. 

In  Reynolds's  experience  there  are  four  times  as  many  epileptics  who 
have  their  attacks  more  frequently  than  once  a  month  as  there  are  who 
have  them  at  long  intervals;  but  I  am  disinclined  to  agree  with  him 
"  that  males  are  more  subject  to  monthly  attacks  than  females,  and  that 
attacks  in  the  latter  are  not  as  a  rule  monthly  seizures." 

I  discover  every  day  numerous  verifications  of  the  menstrual  influence. 
In  forty  patients  I  find  that  eighteen  occur  during  or  just  after  the  days 
the  woman  has  her  catamenia ;  and  in  one  case  much  interest  arises  from 
the  fact  that  there  was  dysmenorrhosa,  and  that  when  this  was  relieved 
the  attacks  disappeared. 

In  many  chronic  cases,  especially  when  there  are  complications,  there 
is  rarely  any  regularity  in  the  appearance  of  the  attacks.  In  the  Epileptic 
Hospital,  on  BlackwelFs  Island,  I  find  extreme  variation  in  their  number  ; 
and  there  are  patients  under  treatment  who  have  had  but  three  or  four 
attacks  in  one  year,  while  there  are  others  who  generally  have  from  five 
to  thirty  each  week  ;  but  this  great  frequency  is  exceptional.  The  attacks 
of  petit  mal  are  much  more  numerous,  but  from  their  very  transitory  cha- 
racter it  is  difficult  to  make  any  estimate  which  is  at  all  useful.  The 
irregular  forms  of  the  disease  are  of  greater  interest  as  curiosities  than 
anything  else,  but  derive  some  importance  from  their  medico-legal  bearing. 

IRREGULAR  ATTACKS.         , 

There  may  be  a  form  known  as  aborted  epilepsy,  which  consists  in  the 
expression  of  all  the  features  of  ordinary  haut  mal,  without  complete  loss  of 
consciousness.  The  attacks  may  occur  in  the  course  of  ordinary  epilepsy. 

The  most  peculiar  examples  of  irregular  seizures  are  described  by  Falret, 


314  BULBAR    DISEASES. 

Hughlings  Jackson,  and  others.  While  in  this  state  the  patient  will  do 
the  most  eccentric  things  imaginable,  the  mind  being  apparently  in  a  con- 
dition of  vacuity,  and  the  individual  becomes  more  an  automaton  than  a 
human  being. 

Mesnet.  of  the  St.  Antoine  Hospital,  came  across  a  very  interesting  <•;!-«•, 
which  he  describes  in  the  Gazette  ffebdomadaire,  July  17,  1874.  The 
patient  has  been  known  as  the  "  Automatic  Man,"  and  his  history  is  as 
follows : — 

"  A  young  man  during  the  late  war  had  a  portion  of  the  left  parietal  bone, 
about  eight  centimetres  in  extent,  carried  away  by  a  ball.  Hemiplegin  <>t 
the  right  side  was  the  consequence,  but  this  gradually  disappeared.  For 
some  time  past  he  has  been  the  subject  of  attacks,  lasting  from  twenty- 
four  to  forty-eight  hours,  attended  by  very  extraordinary  phenomena. 
During  these  he  seems  to  act  exactly  like  an  automaton,  walking  continu- 
ously, incessantly  moving  his  jaw,  knitting  his  brow,  and  appearing  al>-o- 
lutely  insensible  to  all  that  surrounds  him.  Not  uttering  a  word,  he  walks 
straight  forward,  and  when  he  meets  with  an  obstacle,  stops  short,  explores 
it  with  his  hand,  and  tries  to  pass  on  one  side  of  it.  Surrounded  by  a 
circle  of  persons,  he  stops  at  each,  and  endeavors  to  pass  by  the  intervals 
formed  by  their  joined  hands,  then  turns  back,  comes  in  contact  with  the 
next  person,  and  resumes  his  round.  All  this  time  he  never  manife>t> 
the  slightest  consciousness,  just  as  if  he  were  in  a  state  of  somnambulism. 
lie  is  absolutely  insensible  to  pain,  so  that  pins  may  be  thrust  through  the 
cheek  or  into  the  fingers,  or  very  powerful  electrical  shocks  may  be  admin- 
istered without  the  slightest  sensibility  being  manifested.  What,  however, 
is  very  remarkable,  is  that  by  bringing  him  in  relation  with  certain  objects 
we  are  enabled  to  determine  in  him  the  entire  series  of  acts  which  are  cor- 
relative with  the  sensation  thus  aroused.  Thus,  if  a  pen  be  placed  in  his 
hand,  he  seeks  for  ink  and  paper,  and  writes  a  letter  in  a  very  good  hand, 
in  which  he  speaks  very  sensibly  about  different  matters  which  concern 
him.  If  a  leaf  of  cigarette  paper  is  placed  in  his  hand,  he  feels  in  his 
jMx-ket  for  the  tobacco,  rolls  up  the  cigarette  very  adroitly,  and,  having 
found  his  match-box,  lights  it.  If  the  match  be  extinguished  just  as  it 
reaches  the  cigarette,  he  finds  another,  and  that  several  times,  until  he  is 
allowed  to  light  his  cigarette.  If  at  the  moment  when  the  match  is  ex- 
tinguished, another  already  lighted  is  presented  to  him  in  its  place,  it  is 
ini|Ktsi4ible  to  induce  him  to  light  the  cigarette  by  means  of  the  substituted 
match,  lie  allows  his  moustaches  to  become  burned  without  offering  any 
resistance,  but  he  will  not  employ  the  light  thus  presented  to  him.  If 
chopped  eharpie  be  placed  in  his  pocket  instead  of  his  tobacco,  he  makes 
the  cigarette  with  this,  and  lights  and  smokes  it  without  seeming  to  pay 
any  attention  to  what  he  is  smoking. 

Among  the  various  experiments  devised  by  Dr.  Mesnet,  there  is  one 
which  is  particularly  curious.  The  young  man  is  a  singer  at  concerts  by 
profession,  and  if  gloves  be  placed  in  his  hands  he  immediately  puts  them 
on.  and  searches  for  paper.  When  a  roll  of  this,  resembling  music  in  form, 
is  given  to  him,  he  places  himself  in  the  proper  jwsition  and  begins  to  sing. 
It  would  seem,  in  fact,  that  tactile  sensation  induced  in  him  becomes  the 
point  of  departure,  and  as  if  of  escape,  of  a  series  of  acts  correlative  to  this 
initial  sensation — acts  which  he  accomplishes  automatically,  without  letting 
them  deviate  from  their  habitual  and  regular  succession.  Lastly,  it  is  to 
be  noted  that,  while  in  this  singular  condition,  the  patient  steals  all  that 


EPILEPSY.  315 

comes  within  his  grasp.  If  he  touches  any  person,  he  feels  for  his  watch- 
pocket,  and  invariably  detaches  the  watch  and  puts  it  in  his  own  pocket, 
whence  it  may  be  immediately  removed  without  his  making  the  slightest 
opposition.  The  crisis  once  over,  he  has  no  recollection  whatever  of  what 
he  has  been  doing,  and  becomes  again  perfectly  reasonable."1 

An  irregular  form  of  the  disease  is  known  as  "  masked  epilepsy."  The 
patient  in  this  state  may  not  fall  to  the  ground,  but  while  in  a  state  of  un- 
consciousness will  evince  a  great  deal  of  muscular  activity.  An  epileptic 
in  my  ward  is  in  the  habit  of  tearing  through  the  hall,  colliding  with  such 
patients  as  may  happen  to  be  in  ber  way,  and  finally  recovering  conscious- 
ness, when  she  has  no  recollection  of  her  attack.  I  have  noticed  the  same 
phenomena  in  other  cases. 

Another  form  is  connected  with  the  commission  of  purposeless  acts. 
Hammond  reports  the  case  of  a  gentleman  who  disappeared  and  travelled 
about  the  country  for  some  days,  and  when  found  could  not  give  the 
slightest  history  of  his  whereabouts.  The  individual,  in  reality,  leads  a 
double  life,  and  while  the  automatic  state  prevails  he  may  commit  deeds 
of  violence  which  may  subsequently  cause  him  a  great  deal  of  trouble ; 
and  in  such  cases  only,  the  history  of  undoubted  epilepsy  should  alone  be 
sufficient  to  exonerate  him.  I  believe  it  is  strongly  improbable  that  there 
is  ever  an  attack  of  masked  or  aborted  epilepsy  without  expression  of  some 
of  the  evidences  of  the  true  paroxysm. 

The  sequences  of  epilepsy  are  various,  but  it  does  not  necessarily 
follow  that  any  mental  impairment  should  result.  It  is  true  that  in 
some  cases  such  a  termination  is  possible.  Idiocy  and  epilepsy  some- 
times go  together,  but  it  must  be  remembered  that  the  former  is  a  con- 
genital state.  Examples  of  general  mental  failure  are  by  no  means  rare, 
and  in  some  cases  the  disease  slowly  undermines  the  patient's  intellectual 
condition.  An  apathetic  state  is  the  primary  result.  Any  one  who  has 
seen  one  of  these  old  cases  (especially  if  the  patient  be  the  victim  of  petit 
mal'),  with  dull  fishy  expression  of  the  eyes,  a  leaden,  sallow  countenance, 
a  full  lip  with  imperfectly  defined  vermilion  border,  sluggish  cutaneous 
circulation,  loss  of  memory  and  dulness  of  wits,  will  recognize  the  condi- 
tion I  have  endeavored  to  describe.  An  epileptic  convulsion  in  infancy 
may  give  rise  to  cerebral  hemorrhage  from  a  vessel  ruptured  during  the 
paroxysm,  but  the  accident  is  almost  unheard  of  in  adult  life. 

Epileptic  mania,  which  Reynolds  considers  to  occur  in  about  one-tenth 
of  all  the  cases,  is  not  confined  to  any  particular  time.  It  may  occur  be- 
fore the  attacks,  or,  as  is  more  often  the  case,  succeed  them.  In  this  con- 
dition epileptics  may  be  occasionally  very  dangerous,  and  give  way  to 
outbursts  of  violence,  for  which,  of  course,  they  are  entirely  irresponsible. 

A  man  who  was  a  patient  in  the  out-door  department  of  the  N.  Y.  State 
Hospital  for  Diseases  of  the  Nervous  System,  and  who  had  been  treated 
by  my  confrere,  Dr.  J.  J.  Mason,  for  epilepsy  for  a  long  time,  was  subse- 
quently discharged,  as  it  was  supposed,  cured.  A  month  or  two  after- 

1  Med.  Times  and  Gazette,  July  25,  1874. 


316  BULBAR    DISEASES. 

wards,  having  an  attack  which  was  undoubtedly  epileptic  mania,  he  pur- 
sued his  wife  through  the  streets,  and,  drawing  a  pistol,  shot  her  through 
the  heart.  After  the  deed  he  expressed  great  remorse,  and  gave  himself 
up  to  the  authorities,  hut,  notwithstanding  the  medical  testimony,  was 
sentenced  to  the  State's  prison  for  life. 

Causes Of  the  one  hundred  and  eighty-three  cases  of  epilepsy  I 

have  seen  at  various  times,  the  ages  at  which  the  disease  appeared  were 
as  follows : — 

Male.  Female.  Total. 

Under  10  years                                             16  10  26 

Between  10  and  20  years                             23  48  71 

Between  20  and  30      "             .         .         27  14  41 

Between  30  and  50      "                                 29  11  40 

Over  50                        "                                 4l  1  5 

99  84  183 

Reynolds  and  Hammond  show  very  much  the  same  result.  The  former 
saw  one  hundred  and  seventy-two  cases,  and  the  latter  five  hundred  and 
seventy-two. 

Hugon*  has  recently  made  a  valuable  addition  to  the  literature  of  epi- 
lepsy in  an  excellent  brochure  upon  the  subject  of  etiology. 

He  gives  a  table  prepared  by  Martinet  to  show  the  proportion  of  cases 
beginning  between  the  10th  and  20th  years. 

Of  307  cases  collected  by  Musset,  there  were  .         .107 

"     68  "  "  *   Herpin,           "  .-        .       27 

"     83  "  Maisonneuve,  there  were        .       46 

"  306  "  "  Alegre,                       "  .     105 

"   106  "  Leuret,  "  .       42 

"  230  "  "  Moreau,                       "  .        76 

"     43  "  "  Dunaut,                       "  .       26 

"     70  "  Pelusiauve,  "  -17 

"     75  "  "  Dussart,                       "  .       40 

It  will  therefore  be  seen  that  nearly  half  of  all  the  cases  begin  before  the 
twentietli  year.  Bean  collected  273  cases,  43  of  which  began  between  the 
fith  and  12th  years;  49  between  the  12th  and  IGth  years;  and  17  be- 
tween the  IGth  and  20th  years. 

The  attacks  of  early  life  are  exceedingly  irregular,  and  may  begin  as 
jMiorly  develop!  paroxysms,  which  are  by  many  classified  under  that 
most  convenient  term  eclampsia,  which  oftentimes  means  nothing.  A 
number  of  these  attacks  of  an  undefined  type  usually  precede  the  genuine 
explosion  of  the  real  disease. 

In  regard  to  sox,  it  may  be  said  that  Beaumes,  Esquirol,  and  Moreau 
were  of  the  opinion  that  the  disease  was  more  confined  to  women  than 
men ;  but  on  the  other  hand  Celsus,  Joseph  Frank,  Leuret,  and  Sandras, 
as  well  as  Hammond,  Reynolds,  and  others,  take  the  opposite  ground. 

In  two  of  these  cases  there  was  an  indication  of  syphilis. 
*  K6cherches  sur  les  Causes  de  1'Epilepsie,  etc.,  Paris,  1876. 


EPILEPSY.  317 

From  the  number  of  cases  I  have  collected  and  tabulated,  I  am  inclined 
to  adopt  the  same  view  as  the  latter. 

Of  HugonV  cases,  32  in  number,  25  were  men,  and  7  women. 

Professions  seem  to  have  very  little  to  do  with  the  production  of  the 
disease,  if  we  except  bartenders  and  liquor-dealers. 

In  regard  to  the  predisposing  influence  of  temperament,  climate,  .and 
season,  it  has  been  shown  by  Foville,  3Iarce,  Falret,  and  Delasiauve,  that 
the  nervous  and  sanguine  temperaments  predispose  to  the  development  of 
the  disease.  Maisonneuve  found  that  of  65  cases,  25  were  of  a  sanguine 
and  20  of  a  nervous  temperament.  Moreau  considers  that  epilepsy  is 
more  frequent  in  winter  than  in  summer,  while  others  take  the  opposite 
view.  Whether  climate  affects  the  development  of  epilepsy,  I  am  unable 
to  say;  but,  after  very  carefully  conducted  experiments  in  regard  to  the 
influence  of  temperature,  I  am  prepared  to  state  most  decidedly  that  the 
attacks  are  much  more  frequent  whenever  there  is  a  sudden  change  of 
weather. 

A  writer  in  the  JRevista-Sperimentale,  of  May  or  August,  1875,  has 
given  tables  showing  the  influence  of  atmospheric  changes,  temperature, 
etc.,  upon  the  occurrence  of  attacks.  At  that  time  I  began  a  series  of 
observations  at  the  Epileptic  Hospital.  These,  when  compared  with  the 
accurately  taken  charts  of  temperature,  barometric  pressure,  wind,  etc., 
of  the  Health  Department,  conclusively  prove  the  truth  of  the  assertion  I 
have  just  made.  The  number  of  attacks  seemed  to  increase  just  at  the 
change  ;  and  a  very  hot  day,  followed  by  a  cool  one,  would  show  an  in- 
crease of  from  ten  to  fifteen  seizures  among  my  patients  during  the  cool 
day,  and  vice  versa. 

The  influence  of  heredity  is  more  strongly  shown  in  epilepsy  than  in 
any  other  nervous  disease,  except  it  may  perhaps  be  progressive  muscular  //• 
atrophy.  In  cases  of  my  own  the  taint  can  be  traced  back  for  several 
generations  either  by  epilepsy,  neuralgia,  insanity,  or  other  nervous  dis- 
eases. In  one  case  the  maternal  grandfather  died  insane,  the  paternal 
grandfather  died  of  apoplexy,  the  mother  was  living  though  subject  to 
neuralgia,  one  brother  had  chorea,  and  the  other  had  committed  suicide  in 
a  fit  of  temporary  insanity.  Other  examples  are  very  much  like  this. 
Leuret2  found  among  126  epileptic  cases  that  there  was  a  history  of  he- 
reditary epilepsy  in  seven  cases.  Beau's3  experience  was  equally  interest- 
ing. Of  273  epileptics,  there  was  hereditary  predisposition  in  18  cases. 
Leech  and  Fox4  fixed  the  proportion  of  epileptics  in  whom  hereditary 
taint  was  found  at-36.8  per  cent.,  which,  as  far  as  I  can  judge,  is  no  exag- 
geration. Reynolds5  states  that  in  the  upper  classes  this  hereditary  pre- 
disposition exists  to  a  much  greater  extent,  but  calls  attention  to  the  diffi- 

1  Op.  cit.,  p.  7. 

2  Leuret:   Recherches  sur  1'Epilepsie,  Arch.  G6n.  de  M6d.,  1843. 

3  Archiv.  G6n.  de  M6d.,  1836. 

4  Manchester  Med.  and  Surg.  Reporter,  quoted  by  Reynolds. 

5  Syst.  of  Med.,  vol.  ii.  p.  295. 


318  BULBAR    DISEASES. 

culty  of  obtaining  information.  I  have  often  been  disappointed  in  getting 
reliable  information,  for  this  "skeleton  in  ^the  closet"  is  krpt  closely 
guarded.  I  have  been  repeatedly  astonished'  to  find  how  strong  this  ele- 
ment is  in  the  higher  walks  of  life.  In  one  family  I  find  a  long  succession 
of  insane  ancestors,  idiot  children,  and  dissolute  progeny,  which  fully 
accounted  for  the  transmission  of  the  disease.  It  is  a  fact,  however,  that 
it  does  not  follow  that,  because  a  parent  has  been  epileptic,  the  offspring 
shall  inherit  the  disease.  Voisin  found  among  96  cases  24  which  followed 
hereditary  alcoholism  and  phthisis.  It  is  often  due  in  the  first  instance 
to  exciting  causes,  which,  if  removed,  would  probably  be  followed  by  dis- 
appearance of  the  disease. 

As  to  exciting  causes,  I  may  enumerate  bad  habits,  excessive  venrry. 
syphilis,  and  uterine  disease,  which  last  I  believe  to  be  one  of  the  most 
important  of  all.  Fright,  grief,  anxiety,  overwork,  blows  on  the  head, 
and  other  traumatisms,  also  enter  extremely  into  the  etiology  of  the  dis- 
ease ;  and  the  disorders  of  digestion  and  the  exanthematous  di.-casrs  often 
play  a  j«irt  in  its  causation.  Onanism  is  a  very  common  cause;  and  of  24 
male  cases  I  have  seen  during  the  past  year,  this  vice  existed  in  9.  I 
may  extract  the  following  data  from  a  paper  which  I  read  before  the 
American  Neurological  Association  at  their  last  meeting: — 

One-third  of  these  patients  (from  the  Epileptic  Hospital)  suffered  from 
intercurrent  diseases;  two  had  advanced  phthisis;  several  had  nephritic 
disease;  and  a  great  many  were  anaemic.  In  regard  to  the  complicating 
neuroses,  I  find  that  twelve  were  subject  to  headache,  two  were  heiniplegic 
(right),  the  epilepsy  following  the  hemiplegia,  two  suffered  from  sclem-is 
(one  locomotor  ataxia,  the  other  diffused  cerebral  sclerosis),  and  one  was 
an  idiot. 

"When  we  came  to  examine  into  the  causes  we  found  more  difficulty  than 
we  anticipated.  The  intelligence  and  memory  were  much  below  par  in 
all.  Scarlatina  and  variola  preceded  the  disease  in  two,  syphilis  in  one. 
In  nine  the  attacks  were  connected  with  menstrual  irregularities  and  ute- 
rine disease  (versions  and  flexions),  two  of  these  were  masturbators  (by 
confession),  one  of  whom  has  been  cured  since  the  habit  was  broken.  One 
case  only  was  traumatic,  four  were  congenital,  and  several  gave  absurd 
answers  which  were  unsatisfactory.  These  are  examples  of  chronic  cases, 
and  of  course  many  arc  intractable. 

Morbid   Anatomy   and    Pathology The   variety  of  morbid 

appearances  that  have  been  found  from  time  to  time  give  no  satisfactory 
explanation  of  the  pathology  of  this  disease,  and  we  will  not  enter  exten- 
sively into  their  discussion.  Spicula  of  bone  growing  into  the  brain-sub- 
stance, thickened  meninges,  deformities,  or  depressions  of  the  cranial 
bones,  vascular  anomalies,  cysts,  tuberculous  deposits,  softening,  and  a  host 
of  other  changes  have  been  observed.  Some  of  these  are  important 
appearances  which  should  not  be  dismissed  too  hurriedly.  Undoubtedly 
the  osseous  changes  are  quite  satisfactory  causes.  In  three  cases  1  found 
spiculae  or  nodules  or  bone  growing  into  or  pressing  upon  the  cerebrum. 
In  one  of  these  the  exostosis  had  attained  a  length  of  one  inch,  and  varied 


EPILEPSY.  319 

from  one-eighth  to  one-quarter  of  an  inch  in  diameter.  In  other  cases  I 
have  seen  decided  depressions  of  the  parietal  bones,  which  infringed  to  a 
great  extent  upon  the  brain-substance  beneath.  As  far  as  the  deep  lesions 
go,  nothing  very  conclusive  has  been  found.  Van-der-Kolk  has  dwelt 
at  length  upon  the  increased  vascularity  of  the  medulla  and  the  softened 
patches  sometimes  present,  but  these  changes  are  just  as  likely  to  be  the 
results  of  the  disease  as  they  are  to  be  the  lesion  which  produces  the 
Convulsion. 

It  seems  likely,  however,  that  the  investigations  of  Cazauvieilh  and 
Bouchet,  Bourneville,  Charcot,  and  Delasiauve  in  France,  as  well  as  those 
of  Meynert  in  Germany,  must  throw  some  light  upon  the  pathology  of 
this  puzzling  disease.  All  of  these  observers  found  distinct  induration  of 
the  cornu  ammonis,  or  pes  hippocampi,  which  is  known  to  be  situated 
in  the  lateral  ventricle.  Cazauvieilh1  reports  eighteen  autopsies  made  at 
La  Salpetriere.  In  nine  of  these  one  or  both  of  the  cornua  ammonis 
were  indurated,  and  at  the  same  time  there  was  induration  of  the  white 
matter  of  the  hemispheres.  Bouchet,2  in  forty-three  cases,  found  the  same 
condition  of  affairs.  He  says,  "  La  corne  d'ammon  est  la  partie  cerebrale 
qui  a  le  plus  frequemment  presente  1'induration.  Cette  alteration  a 
souvent  ete  si  frappante,  et  quelquefois  si  constante,  que  bien  eVidente 
neuf  fois  de  suite  pour  quelques  medecins  assistants,  elle  leur  a  donne  la 
conviction  qu'elle  representait  exactement  la  cause  pathologique  de  1'dpi- 
lepsie." 

Bourneville  observed  this  lesion  five  times  out  of  thirty-four  during  the 
years  1866-1874.  Meynert  has  repeatedly  discovered  induration  of  this 
part,  and  considers  it  a  pathognomonic  sign.  In  his  examination  the 
cornua  ammonis  were  found  atrophied,  and  appeared  to  be  of  a  cartilagi- 
nous hardness,  and  had  undergone  a  general  alteration. 

Of  ten  autopsies  that  I  have  made,  six  presented  this  lesion,  and  in  one 
I  found  it  to  be  uncomplicated.  The  other  four  cases  presented  nothing 
distinctive.  In  two  the  left  hippocampus  major  was  indurated,  in  three 
both  were  indurated,  and  in  one  the  right  was  the  seat  of  the  same  change. 
In  one  of  these  the  extreme  exterior  part  of  the  pes  hippocampus  was 
quite  firm  ;  the  little  crenations  or  irregularities  were  more  marked  than  in 
the  healthy  brain,  as  there  had  evidently  been  some  atrophy  with  contrac- 
tion. In  one  the  gray  matter  just  adjacent  to  the  hippocampus  major  con- 
tained several  indurated  patches.  In  two  cases  the  veins  which  skirt  the 
inner  edge  of  the  corpora  striata  at  the  line  of  the  velum  interpositum,  and 
receive  branches  from  these  bodies,  were  quite  distended  with  blood,  as 
were  the  venae  galeni.  The  white  matter  in  both  anterior  lobes  was  quite 
hard  in  three  cases.  In  one  case  there  were  minute  extravasations  throughout 
the  brain  and  in  the  medulla.  In  two  cases  there  was  effusion  into  the 


1  Archiv.  G6n.  de  Med.,  3me  Anne,  1825,  i.,  ix.,  p.  510,  et  4me  Ann6.  1826, 
i.,  v.,  p.  5. 

2  Sur  1'Epilepsie  (Annales  M6d.  Psychologiques,  1853,  1.  v.,  p.  209). 


320  BULBAR    DISEASES. 

lateral  ventricles.  The  cranial  bones  in  one  case  were  found  to  be  con- 
siderably thickened.  In  all  of  the  cases  there  were  evidences  of  great 
meningeal  hypenemia.  In  three  of  these  cases  I  found  microscopical  dis- 
organization of  a  granular  character  of  the  nerve-elements  in  the  medulla. 
The  vascular  walls  were  thickened,  and  at  certain  points  ruptured,  the 
places  of  rupture  having  no  special  pathological  relation  as  far  as  the 
nuclear  involvement  was  concerned. 

In  three  cases  which  are  not  included  in  the  ten  referred  to,  I  found 
osseous  growths.  Although  this  lesion  of  the  cornua  ammonis  very  rarely 
exists  alone,  it  seems  to  be  quite  a  constant  morbid  appearance,  and  it 
now  remains  for  us  to  discover  whether  the  condition  is  peculiar  to 
epilepsy. 

Epilepsy  is,  without  doubt,  an  organic  affection,  the  established  disease 
beginning,  perhaps,  after  a  peripheral  irritation  has  been  transmitted  re- 
peatedly to  the  centres ;  but  after  the  disease  is  fairly  developed,  the  con- 
vulsions are  not  necessarily  produced  by  the  excitement  of  such  distal 
irritation  ;  for,  as  Nothnagel  shows,  in  eases  dependent  upon  a  cicatrix 
the  attacks  are  not,  as  a  rule,  excited  only  by  irritation  of  the  cicatrix. 
The  clinical  features  of  the  disease  prove  the  truth  of  this  rule ;  for,  in 
any  well-established  case,  gastric,  uterine,  or  any  other  reflected  irritation 
may  give  rise  to  the  seizures,  or  they  may  take  place  in  an  apparently  spon- 
taneous manner.  We  must,  therefore,  consider  that  epilepsy  is  a  disease 
of  an  organic  character,  expressing  itself  after  either  some  distal  or  central 
stimulation  in  an  irregular  manner,  or  the  result  of  both.  That  it  is 
connected  with  central  changes  there  is  no  reason  to  doubt ;  though  these 
changes  are  by  no  means  uniform. 

The  experiments  of  Brown-Sequard  have  thrown  much  light  upon  its 
pathology,  though  Nothnagel  and  others  do  not  accept  his  views  in  their 
entirety.  Spinal  epilepsy,  which  has  been  described  by  Brown-Se"quard 
as  an  independent  and  local  affection,  is  thus  spoken  of  by  Nothnagel : 
"  Of  course,  if  we  use  this  designation  (spinal  epilepsy)  for  those  cases 
in  which  an  actually  existing  epilepsy  is  developed  in  consequence  of 
an  affection  of  the  spine,  it  would  have  a  certain  justification.  Still  it 
is  superfluous ;  for  here  the  name  of  secondary  epilepsy,  as  above  pro- 
posed, in,  in  our  judgment,  amply  sufficient.  We  must,  however,  very 
decidedly  protest  against  the  abuse  which  has  recently  come  into  vogue  of 
describing  as  spinal  epilepsy  the  clonic  and  tonic  spasmodic  seizures  which 
occur  as  a  symptom  in  spinal  affections,  which  remain  confined  to  the 
extremities  or  even  to  the  legs,  and  are  not  accompanied  by  any  trace  of 
mental  changes.  With  just  as  much  propriety  could  we  speak  of  a  spinal 
accessory  or  median  epilepsy  in  the  case  of  clonic  twitchings  of  the  mus- 
cles of  the  fingers  or  neck  which  proceed  from  a  peripheral  affection  of 
the  median  or  spinal  accessory  nerve.  In  our  opinion  it  is  most  judicious 
to  let  the  expression  fall  entirely  into  disuse ;  for  on  one  hand  it  is  unne- 
cessary, and,  on  the  other,  it  leads  only  to  confusion." 

The  experiments  of  Brown-S6quard  were  chiefly  made  upon  guinea-pigs. 
He  produced  epilepsy  by  division  of  the  trunk  of  the  sciatic,  internal  pop- 


EPILEPSY.  321 

liteal  and  posterior  roots  of  the  nerves  innervating  the  lower  extremities, 
and  by  injury  of  various  parts  of  the  brain,  the  corpora  quadrigemina, 
and  cerebral  peduncles.  He  also  divided  the  cord  at  different  points  par- 
tially or  completely,  and  found  that  injury  of  the  lower  part  of  the  cord 
seemed  to  have  more  to  do  with  the  subsequent  epilepsy  than  when  the 
upper  part  was  mutilated.  After  these  experiments,  the  first  appearance 
of  epilepsy  occurred  in  from  four  to  six  weeks.  The  attacks  were  either 
spontaneous,  or  followed  irritation  of  certain  parts  of  the  skin  which  were 
included  in  the  so-called  "  epileptic  or  epileptigenous  zone."  This  in- 
cluded the  cheek,  anterior  part  and  side  of  the  neck,  and  a  portion  of  the 
l.;;ck.  This  region  became  anaesthetic,  and  the  hair  usually  fell  out.  Any 
irritation  of  this  tract,  such,  for  instance,  as  pinching,  gave  rise  to  an  at- 
tack. Ultimately  the  anaesthesia  diminished,  and  the  attacks  subsided,  so 
that  it  was  impossible  to  excite  them.  The  "  epileptic  zone"  corresponded 
to  the  side  upon  which  the  nerve  or  cord  injury  had  taken  place. 

Other  forms  of  experimentation  have  produced  convulsive  attacks,  or  a 
condition  resembling  epilepsy.  These  were  blows  upon  the  back  of  the 
head  (Westphall)  ;  irritation  of  the  cortex-cerebri  (Hitzig)  ;  ligation  of 
the  carotids  and  vertebral  arteries  (Cooper,  Hall,  Kussmaul,  and  Tenner); 
irritation  of  the  peripheral  sensory  nerves  (Nothnagel,  Krauspe).  The 
labors  of  these,  as  well  as  others,  indubitably  show  that  the  epileptic  at- 
tack is  connected  with  cerebral  antemia,  and  the  experimental  production 
of  this  vascular  state  when  irritation  of  peripheral  sensory  nerves  has  been 
made  furnishes  another  link  in  the  chain. 

The  question  of  localization  next  arises.  Brown-Sequard,  Schiff,  Rey- 
nolds, and  Kussmaul,  and  Tenner  have  all  demonstrated  that  the  me- 
dulla oblongata  is  the  probable  pathological  seat  of  the  disease.  It  has 
been  proved  by  them  that  a  so-called  "  convulsive  centre"  is  here  located, 
which,  when  excited  by  reflex  stimuli,  gives  rise  to  extensive  spasms  of 
both  kinds  of  the  voluntary  muscles  ;  that  whether  the  irritation  comes 
<>x  chorda  or  ex  cerebro,  there  is  a  primary  bulbar  ^congestion,  a  cerebral 
anaemia,  and  a  secondary  cerebral  congestion  ;  that  such  congestion  follows 
reflex  spasm  of  the  cervical  muscles,  and  that  a  condition  of  venous  en- 
gorgement ensues  from  pressure  upon  the  large  vessels  of  the  neck.  The 
pathology  of  the  confirmed  disease  may  be  briefly  stated  as — 

A.  The  existence  of  a  condition  of  reflex  excitability  of  the  medulla 
from  a  long-standing  reflected  irritation. 

B.  An  exciting  impression  transmitted  from  the  periphery,  or  from  a 
central  part. 

C.  The  irritation  of  the  vaso-motor  centre  (described  by  Dittmar  and 
others)  through  congestion  at  the  floor  of  the  fourth  ventricle. 

D.  A  secondary  anaemia  and  hyperremia  of  the  hemispheres. 
The  production  of  symptoms  is  probably  due  to — 

1.  a.  Anaemia  of  the  brain  ;  b.  Consequential  primary  loss  of  conscious- 
ness, etc. 

2.  Irritation  of  "  convulsive  centre,"  with  tonic  muscular  contraction, 

3.  a.  Irritation  of  nuclei  of  lower  cranial   nerves ;    b.  Consequential 

21 


322  BULBAR   DISEASES. 

asphyxia.  Contniction  of  muscles  of  neck,  pressure  upon  vessels,  etc., 
secondary  stupor,  clonic  convulsions. 

Van-der-Kolk1  explains  tlie  tongue-biting  as  the  result  of  irritation  of  the 
nuclei  of  the  hypoglossal  nerves. 

The  observations  of  Hughlings  Jackson1  and  Hitzig  throw  much  light 
upon  the  pathology.  The  former  proves  "  that  those  p:uts  are  \voiu  to 
sutler  first  and  most  which  serve  in  the  voluntary  (special)  operations, 
and  those  last  and  least  which  serve  in  the  more  automatic  (general  opera- 
tions)." 

Briefly  to  illustrate  this,  he  quotes  from  an  article  in  the  Lancet, 
demonstrating  that  the  three  points  at  which  the  convulsions  often  begin 
are:  "  (1)  in  the  hand  ;  (2)  in  the  face,  in  the  tongue,  or  both  ;  (3)  in  the 
foot." 

This  confirms  the  idea  that  the  onset  begins  in  the  parts  devoted  more 
particularly  to  the  execution  of  voluntary  movements.  He  has  been 
enabled  to  prove  that  in  this  manner  the  parts  first  attacked  are  those 
which  are  more  commonly  affected  in  hemiplegia.  He  also  calls  attention 
to  the  phenomenon  of  aphasia,  with  epilepsy  beginning  in  the  right  cheek. 

"•  Epilepsies,"  he  says,  "  are  the  results  of  the  second  class  of  functional 
changes ;  they  are,  sj>eaking  briefly,  discharging  lesions.  But  there  are 
many  varieties  of  discharges.  Defined  from  the  paroxysm,  an  epilepsy  is 
a  sudden,  excessive,  and  rapid  discharge  of  .gray  matter  of  some  part  of  the 
lirain  ;  it  is  a  local  discharge.  To  define  it  from  the  functional  alteration, 
we  say  there  is  in  a  case  of  epilepsy,  gray  matter  which  is  so  abnormally 
nourished  that  it  occasionally  reaches  very  high  tension  and  very  unstable 

equilibrium,  and,  therefore,  occasionally  explodes It  will  be 

observed  that  the  discharging  lesion  of  epilepsy  is  supposed  to  be  a  perma- 
nent lesion  ;  there  is  gray  matter  which,  since  it  is  permanently  under 
conditions  of  abnormal  nutrition,  is  permanently  abnormal  in  function. 
That  this  permanent  abnormality  is  a  varying  state,  has  been  said  ;  it  has 
been  remarked  that  the  gray  matter  occasionally  reaches  high  tension, 
and,  therefore,  occasionally  discharges  (or  is  discharged).  There  are 
waves  of  stability  and  instability.  It  follows  from  this  that  the  first  fit  is 
supposed  to  be  a  discharge  of  a  part  which  has  for  some  time  before  been 
in  a  state  of  malnutrition  ;  and  a  still  further  inference  i»  that  such  'causes' 
of  epilepsies  as  fright  are  only  determining  causes  of  \\\c  first  explosion. 
Many  of  the  premonitory  symptoms  of  a  first  attack  are  probably  results 
of  slight  discharges;  they  are  miniature^/iVs." 

That  irritation  of  the  auditory  apparatus  may  give  rise  to  a  variety  of 
epilepsy  there  can  be  no  doubt,  but  such  cases  I  believe  to  be  rare. 
Brown-Sequard*  states  that  Mr.  Ilinton,  an  Knglish  surgeon,  has  reported 
several  where,  after  death,  no  lesion  was  discovered,  except  evidences  of 
disease  of  the  middle  ear.  My  friend  Dr.  lloosa  tells  me  that  out  of  five 

1  Brain  and  Spinal  Cord,  Sydftiluun  Trans. 

*  W.  Riding  Reports,  vol.  iii.  p.  315,  et  seq. 

*  Central  Nervous  System,  p.  96,  and  Claz.  M6J.  de  Paris,  1842,  p.  25. 


EPILEPSY.  323 

or  six  thousand  cases  of  aural  disease  he  has  seen,  he  does  not  remember 
but  one  of  this  kind  : — 

John  W.  P ,  aged  15  years  and  6  months,  a  stout  and  apparently 

healthy  boy,  well  nourished,  and  presenting  no  external  evidences  of  dis- 
ease ;  family  history  good.  His  mother  stated  that  he  had  always  been 
a  rather  dull  boy,  and  that  at  school  he  was  generally  behind  in  his  studies, 
and  did  not  seem  to  learn  easily,  and  when  sent  on  errands  he  was  unre- 
liable and  forgetful.  There  is  no  history  of  injury  or  sudden  fright,  nor 
lias  there  been  any  known  predisposing  or  exciting  cause,  but  at  the  age 
of  eight  years  he  had  a  severe  attack  of  scarlatina,  which  left  him  with  a 
remaining  otitis,  most  severe  on  the  right  side,  and  resulting  in  a  profuse 
discharge  of  pus,  which  still  continues  in  a  modified  degree,  but  is  not  so 
excessive  as  it  was  a  month  ago.  About  six  weeks  ago  he  began  to  syringe 
his  ears  with  a  carbolic  acid  solution,  which  had  the  effect  of  removing  a 
large  mass  of  what  was  probably  inspissated  pus  ;  and  his  hearing,  which 
had  before  been  quite  defective,  became  greatly  improved,  and  he  no  longer 
complained  of  various  subjective  noises,  such  as  buzzing  and  roaring. 
When  the  quantity  of  discharge  was  diminished  his  ears  became  painful, 
and  pressure  on  the  mastoid  processes  caused  much  suffering.  Ever  since 
the  scarlatina  he  has  had  frontal  and  occipital  headache,  which  is  always 
constant.  About  a  month  ago  he  had  his  first  epileptiform  attack,  and 
this  occurred  about  noon  one  day  when  he  was  using  his  syringe.  Without 
warning  he  suddenly  fell  to  the  floor,  became  convulsed,  and  in  a  few 
minutes  recovered,  and  did  not  fall  asleep ;  but  a  semi-unconscious  state, 
however,  supervened. 

The  next  attack  came  on  four  days  after,  at  3  P.M.  While  he  was 
chatting  with  a  friend,  he  suddenly  stopped  talking,  and  fell.  This  attack 
was  much  more  violent  than  the  first  one.  They  now  become  more  and 
more  frequent,  until  about  two  weeks  ago,  when  on  one  occasion  lie  had 
fifteen  during  twenty -four  hours.  Since  then  he  has  not  had  so  many, 
having  had  between  one  and  five  attacks  every  day  but  one,  which  was 
the  only  day  he  missed  the  attack  since  the  commencement.  During  some 
of  the  attacks  he  is  very  violent,  while  in  others  not  so  much  so.  His  ap- 
petite has  been  irregular  for  some  time  past.  An  examination  made  by 
Dr.  Baldwin,  House-physician  of  the  Epileptic  and  Paralytic  Hospital, 
and  myself,  revealed  tenderness  on  pressure  over  mastoid  processes,  but 
mostly  on  the  right  side.  He  has  had  no  definite  aura,  but  peculiarsensations 
which  he  cannot  describe,  preceding  his  attacks.  He  complains  of  vertigo 
and  nausea,  and  muscular  weakness  after  the  slightest  exertion.  He  in- 
variably returns  to  consciousness  almost  immediately  after  the  attack,  at- 
tempts to  rise  and  walk,  but  is  usually  quite  feeble. 

Examination  of  Ears R. :  Discharge  scanty,  thin,  and  sero-purulent ; 

and,  on  examination,  the  membranum  tympani  is  found  absent.  The  tick 
of  a  watch  is  heard  only  when  the  watch  is  pressed  against  the  ear.  A 
roaring  sound  is  always  present. 

L. :  The  same  examination  shows  more  or  less  congestion  of  the  tympa- 
num, with  evident  signs  of  otitis  media  ;  but  there  is  not  so  much  pain  on 
this  side,  and  the  hearing  is  better,  the  ticking  of  the  watch  being  heard 
at  three  inches. 

Patient  has  complained  lately  of  deep,  severe  pain  in  the  frontal, 
but  extending  back  to  the  occipital  region.  With  this  pain  there  is 
dizziness,  especially  when  he  stands,  thus  making  it  difficult  for  him  to 


324  BULBAR    DISEASES. 

preserve  his  equilibrium,  which  is  strikingly  shown  by  his  irregular  move- 
ments. When  sitting  up  in  bed,  he  complains  that  objects  move  up  ;iml 
down,  ivnd  not  horizontally,  as  we  should  expect  to  find  in  ordinary  audi- 
torv  vertigo  ;  and  a  very  interesting  and  peculiar  symptom  arc  tin  move- 
ments he  makes  to  preserve  his  relation  with  surrounding  objects,  his  body 
moving  up  and  down  and  his  head  swaying  strangely.  lie  is  very  suscep- 
tible to  noises  and  bright  lights,  either  being  capable  of  inducing  a  spasm 
at  times.  Vomiting  froth  an  empty  stomach  is  occasional,  with  dilatation 
of  pupils.  The  vision  of  right  eye  is  at  times  entirely  lost,  but  at  others 
is  unimpaired.  Muscie  volitantes  are  frequently  complained  of.  Exami- 
nation of  urine  affords  negative  results. 

Observations  during  an  attack  or  convulsion,  which  occurs  at  no  regu- 
lar intervals,  but  is  a  constant  result  of  irritation  of  the  internal  auditory 
apparatus : — 

Ear  syringed  at  9.55  A.M.  Patient  calm,  and  not  at  all  nervon*  : 
skin  of  normal  hue  ;  pulse  regular  ;  temperature  normal ;  pupils  somewhat 
dilated.  He  passed  a  good  night,  and  suffered  but  little  pain,  though  his 
vertigo  was  still  troublesome.  He  was  placed  upon  a  bed,  and  the  point 
of  an  ordinary  two-ounce  syringe,  filled  with  tepid  water,  was  inserted  in 
the  external  meat  us  of  the  right  ear,  and  the  contents  gradually  expelled. 
This  caused  some  pain  and  dizziness,  which  increased  as  more  water  was 
injected  ;  and  when  one  ounce  had  been  thrown  in,  the  patient  became 
suddenly  unconscious,  and  the  head  was  drawn  from  one  side  to  the  other 
by  rapid  clonic  contractions  of  the  muscles  of  the  neck,  and  almost  at  the 
same  time  the  convulsion  became  general,  the  muscles  of  the  back  being 
extensively  involved. 

About  five  seconds  after  this,  there  were  clonic  spasms  of  the  muscles 
of  the  jaw,  so  that  the  patient  snapped  his  teeth,  and,  at  the  same  time, 
•forcibly  inspired,  giving  vent   to   a  peculiar  noise  which  might  be  easily 
compared,  by  a  person  of  lively  imagination,  to  the  bark  of  a  dog. 

This  paroxysm  lasted  two  minutes,  and  during  its  continuance  the  pupils 
were  widely  dilated.  The  patient  remained  unconscious  ;  but  then*  was 
neither  pallor  nor  suffusion  of  the  face.  Thirty  seconds  afterwards,  a 
period  of  muscular  relaxation  succeeded,  a  fresh  attack  followed,  during 
which  there  was  more  marked  opisthotonos,  much  more  noise,  but  no 
frothing  at  the  mouth.  Pupils  still  dilated,  though  perhaps  not  so  much 
so  as  at  first,  while  the  skin  was  slightly  suffused  ;  but  there  was  no  duski- 
ness. Duration,  one  and  a  half  minute.  Ten  o'clock  and  thirty  seconds, 
after  slight  relaxation  and  subsidence  of  movements,  the  lateral  jactitation 
of  the  head  again  began  ;  and  at  ten  o'clock  and  one  minute  a  violent  ac- 
cession of  clonic,  and  afterwards  tonic  spasms  made  their  appearance. 
The  eyeballs  had  throughout  been  uncovered,  and  at  first  were  stationary 
and  immovable,  or  almost  so ;  but  now  they  were  agitated  by  nystagmatic 
movements,  and  the  pupils  were  dilated.  This  paroxysm  lasted  but  thirty 
seconds.  At  ten  o'clock  and  three  minutes  there  was  another  seizure, 
during  which  the  left  sterno-cleido-mastoideus  was  involved  in  a  prolonged 
tonic  contraction.  The  pupils  now  partially  returned  to  their  normal  con- 
dition, which  was  one  of  slight  dilatation;  and  at  ten  o'clock  and  four 
minutes  the  patient  became  semi-conscious,  answered  questions  in  mono- 
syllables, and  after  a  few  minutes  recovered  entirely.  The  pulse  suffered 
no  variation,  except,  perhaps,  after  two  minutes  had  elapsed  from  the  be- 
ginning of  the  seizure,  when  it  seemed  to  increase  in  volume,  and  perhaps 
slightly  in  rapidity.  There  was  an  entire  absence  of  any  external 


EPILEPSY.  325 

evidence  of  asphyxia,  which  is  so  marked  in  the  more  familiar  form  of 
epilepsy. 

I  have  ascertained  that  the  convulsions  may  be  precipitated  by  simply 
blowing  into  the  external  auditory  meatus. 

Diagnosis. — Epileptic  attacks  may  be  mistaken  for  the  convulsions 
of  Bright's  disease,  infantile  convulsions,  hysteria,  alcoholism,  opium 
poisoning,  syncope,  and  softening,  and  the  disease  is  occasionally  simu- 
lated by  malingerers  and  others.  I  may  briefly  dispose  of  the  above  : 

1.  Vrzemic  convulsions  are  generally  preceded  by  drowsiness  or  coma, 
delirium,  and  stertor.  The  limbs  may  be  ccdematous,  and  the  urine  con- 
tains albumen. 

'2.  Infantile  convulsions  from  worms,  dentition,  and  other  eccentric 
causes,  are  usually  attended  by  a  febrile  condition.  The  convulsions  are 
of  short  duration,  and  are  characterized  by  complete  loss  of  consciousness. 
The  discovery  and  removal  of  the  cause  usually  effect  a  disappearance  of 
the  attacks. 

3.  Hysteria.     (See  article  Hystero-Epilepsy.) 

4.  Alcoholism  and  opium  poisoning  are  characterized  by  a  more  pro- 
tracted stage  of  unconsciousness  and  a  contraction  of  the  pupils  in  the  latter. 

5.  Fainting  attacks    may   resemble  the   petit-mal,  but    there  are  no 
spasms,  and  the  pulse  is  feeble. 

6.  Softening  and  other  organic  states  give  rise  to  convulsions,  but  the 
accompanying  symptoms  should  enable  the  observer  to  make  the  diagnosis 
in  every  instance. 

Simulated  convulsions  may  deceive  a  careless  person,  but  the  normal 
condition  of  the  pupil,  and  the  eagerness  of  the  individual  to  play  his  part, 
perfectly  which  he  does  not  do,  lead  to  the  detection  of  the  imposition  ; 
and  the  excessive  pallor  of  the  first  stage  can  never  be  simulated. 

The  syphilitic  form  of  the  disease  resembles  much  the  ordinary  variety, 
but  in  some  instances  it  is  of  the  greatest  importance  to  distinguish  it? 
specific  nature,  as  of  course  the  treatment  is  entirely  different  from  that 
employed  in  the  non-specific  disease.  Buzzard,  who  has  given  us  an 
admirable  little  work  on  the  syphilitic  neuroses,  lays  great  stress  upon  the 
necessity  of  recognizing  the  variety  of  pain  as  a  differential  symptom. 

"  If  pain  in  the  head  be  associated  with  convulsive  attacks,"  he  snys, 
"  it  generally  precedes  the  attack  in  syphilitic  convulsions,  and  is  often 

localized  in  one  particular  spot In  simple  epilepsy  (if  it  be 

present)  it  almost  always  follows  the  fit,  is  diffused  over  the  forehead,  and 
is  at  no  time  a  strongly  marked  symptom."  The  age  of  the  patient,  and 
the  time  from  which  the  attacks  date,  are  also  of  great  importance  in  this 
connection.  It  is  not  probable  that  syphilitic  epilepsy  would  begin  early 
in  life,  or,  at  least,  before  puberty,  but  simple  epilepsy  dates  from  early 
childhood. 

Prognosis The  duration  of  the  disease  has  much  to  do  with  the 

prognosis,  and  the  mode  of  origin,  form  of  expression,  and  complicating 
conditions  must  all  be  considered  before  an  opinion  is  given.  If  the 
disease  be  of  idiopathic  origin,  or  if  it  be  due  to  violence,  i.  e.,  injuries  to 


326  BULBAR    DISEASES. 

the  head,  the  prognosis  is  had.  If  it  be  due  to  eccentric  causes  or  syphilis, 
there  is  reason  to  he  hojieful.  Hereditary  predisposition  is  an  obstacle  in 
our  path  which  sometimes  blocks  the  way  to  a  cure.  I  have  found  that 
the  petit  mal  is  also  less  amenable  to  treatment  than  the  severe  form, 
and  that  it  is  pretty  sure  to  produce  an  impaired  mental  condition. 

Reynolds  thinks  that  the  attacks  which  recur  rapidly  are  more  amenable 
than  those  which  take  place  at  long  intervals,  but  this  has  not  been  my 
experience.  If  there  be  any  considerable  congenital  lack  of  intelligence 
the  case  may  be  considered  as  incurable.  The  unfavorable  conditions  are 
the  occurrence  of  a  great  many  attacks  in  a  short  space  of  time,  the  biting 
of  the  tongue,  and  a  condition  which  has  been  known  as  the  "  status  epi- 
lepticus,"  in  which  there  are  a  comatose  condition,  and  a  number  of  fits 
in  close  succession.  Death  from  epilepsy  is  not  common,  and  I  know  of 
but  six  fatal  cases:  five  from  the  disease,  and  one  from  falling  upon  a 
sharp  iron  point  which  penetrated  the  orbit. 

Treatment. — Before  entering  upon  the  discussion  of  particular  modes 
of  treatment,  I  desire  again  to  refer  to  certain  etiological  facts  which  bear 
to  a  great  extent  upon  the  selection  of  remedies. 

I  may  be  pardoned  for  calling  attention  to  practical  points  which 
may  appear  unimportant  to  some;  but  an  experience  gained  from  the 
management  of  a  great  many  cases  teaches  me  that  they  are  to  be  carefully 
considered  in  selecting  a  plan  of  treatment.  These  simple  indications,  I 
sun  convinced,  sire  too  often  overlooked  even  by  painstaking  and  careful 
medical  men.  I  allude  to  the  necessity  for  discovering  the  exciting  cause. 
I  am  every  day  made  to  feel  that  the  idiopathic  cases  do  not  form  so  large 
a  proportion  as  they  were  once  thought  to.  With  this  belief  I  am  satis- 
fied thsit  empiricism  and  routine  management  are  bad  methods.  Any  one 
who  examines  sill  his  cases  thoroughly  will  recognize  the  delicate  shades 
in  epilepsy,  variations  which  are  exhibited  in  other  diseases  presenting 
more  pronounced  and  better  defined  symptoms;  consequently  there  :in> 
evidences  of  pathological  action,  which  sire  not  always  grouped  alike,  ami 
therefore  sill  cases  are  not  to  be  treated  in  the  same  manner.  I  ascribe 
the  moderate  success  I  have  had  in  the  msinsigement  of  this  disease  to  the 
recognition  of  these  differences. 

Not  only  may  obstinate  epilepsy  result  from  masturbation,  but  it  may 
be  due  to  many  of  the  diseases  of  women,  and  it  is  produced  by  eccentric 
irritations  of  various  kinds,  or  by  centric  irritation,  such  as  msiy  be  asso- 
cisited  with  toxsvmia. 

Sir  C'luirles  Locock1  called  attention  to  many  cases  he  had  treated 
where  uterine  irritation  wsis  the  exciting  cause;  and  I  think  others  hsive 
had  the  ssime  experience.  In  one  of  Locock's  cases  the  patient  was 
affected  partieuhirly  at  the  menstrual  periods. 

Some  of  those  peripheral  causes  are  curious  in  the  extreme.  Through 
the  kindness  of  Dr.  Gibney,  of  New  York,  I  was  enabled  to  see  a  child 
who  luid  accidentsilly  injured  her  ear  with  her  parasol,  the  brsiss  tip  of 
which  remained  for  some  time  imbedded  in  the  external  auditory  meatus. 

1  Mcd.  Times  and  Gazette,  May  23,  1853. 


EPILEPSY.  32T 

As  a  result,  convulsions  of  an  epileptic  character  were  caused,  and  it  was 
not  until  some  time  afterward  that  the  foreign  body  was  discovered  and 
removed.  In  another  case  I  treated,  the  epilepsy  was  unmistakably  due 
to  a  bad  habit  the  woman  had  of  wearing  a  number  of  heavy  garments 
about  her  hips,  which  produced  some  uterine  change.  When  this  condi- 
tion of  affairs  was  noticed,  and  the  skirts  removed,  she  immediately  re- 
covered. At  the  root  of  many  epilepsies,  as  well  as  other  neuroses,  are 
reflex  causes — the  starting-point  being  the  organs  of  digestion,  or  those 
contained  in  the  pelvis.  Of  course  the  varieties  of  epilepsy  of  an  idio- 
pathic  nature,  or  those  caused  by  traumatism  or  organic  disease,  will  defy 
the  best  efforts  of  the  physicians. 

In  prescribing  for  our  patient  there  are  five  indications  to  observe : — 

1.  Removal  of  exciting  causes,  if  possible. 

2.  The  diminution  of  exaggerated  reflex  susceptibility  of  the  medulla. 
.'3.  Equalization  of  cranial  circulation. 

4.  Abortion  of  paroxysms. 

5.  Improvement  of  general  condition. 

For  the  accomplishment  of  these,  it  is  imperative  that  a  judicious  and 
discreet  selection  of  drugs  should  be  made ;  and  among  those  which  are 
the  most  effective  I  may  mention  : — 

The  Bromides :  sodium,  potassium,  ammonium,  calcium,  lithium,  iron. 
Chloral  hydrate.  Mercury. 

Belladonna.  Arsenic. 

Digitalis.  Amyl-nitrite. 

Strychnine.  Tri-nitro-glycerin. 

Ergot.  Cod-liver  oil. 

(FF.  23,  84,  29,  44,  77,  76,  43,  85,  86,  32.) 

I  have  not  classified  these  remedies,  as  it  is  unnecessary  to  do  so ;  but 
will  now  say  a  word  in  regard  to  their  usefulness. 

No  one  drug  can  be  declared  a  specific,  as  I  am  sorry  to  see  has  been 
done;  and  we  must  not  be  too  eager  to  accept  the  sanguine  results  of 
certain  over-enthusiastic  authorities,  and  be  governed  thereby.  I  allude 
more  especially  to  the  almost  universal  use  of  the  bromides  to  the  exclu- 
sion of  everything  else,  and  also  to  their  employment  in  quantities  which 
often  ruin  the  patients,  or,  at  any  rate,  produce  a  condition  of  diminished 
vitality,  which  is  inconsistent  with  any  hope  of  success.  Badcliffe's1  idea 
in  this  respect  is  a  good  one  :  "  There  is  reason  to  believe  that  the  thera- 
peutics of  convulsion  must  be  based  upon  the  notion  that  vital  power  has 
to  be  reinforced,  and  not  upon  the  contrary  opinion."  What  the  proper 
•lose  is  has  not  been  clearly  settled  by  any  one.  There  are  neurologists 
who  believe  in  toxic  doses,  and  there  are  others  who  prescribe  quantities 
which  are  almost  small  enough  to  be  inert.  In  England  it  has  been  the 
custom  to  prefer  the  very  small  doses.  I  have  seen  the  prescription  of  a 
very  distinguished  general  practitioner,  who  thinks  five  grains  of  the 
bromide  of  potassium  a  sufficient  dose.  Ringer2  recommends  from  30  to 

1  Pain,  Epilepsy,  and  Paralysis,  p.  215. 

2  Handbook  of  Therapeutics,  p.  92. 


328  BULBAR    DISEASES. 

GO  grains  in  the  day ;  Radcliffe,1  45  grains  ;  Russell  Reynolds,*  30  to  90 
grains  ;  Bartholow,8  30  to  240  ;  and  Hammond,4  90  to  240  grains  during 
the  day. 

Handfield  Jones5  remarks  that  there  is  a  great  difference  in  the  tole- 
rance of  individuals  in  regard  to  the  bromides — some  persons  not  being 
able  to  stand  five  grains,  while  others  will  not  be  affected  by  doses  of  !<•-- 
than  forty  grains. 

My  own  experience  has  taught  me  that  the  best  effect  can  be  gained  by 
the  repeated  administration  of  sixty  grains  in  the  twenty-four  hours.  Tin- 
larger  doses  produce  rapid  bromism,  while  the  medium  dose  seems  to  be 
better  appropriated,  but  will  do  just  as  much  mischief  in  the  way  of 
bromism  as  the  larger  ones,  if  given  for  a  length  of  time.  My  records 
show  me  that  the  average  time  for  development  of  symptoms  of  this  kind 
is  about  three  months,  while  anaesthesia  of  the  fauces  is  produced  in  a  few 
weeks,  or  even  a  much  shorter  time  ;  and  I  agree  with  others  that  it  is 
necessary  to  produce  this  condition  before  we  can  say  that  the  medicine 
has  produced  its  physiological  effect.  But  when  once  reached,  the  further 
toxic  action  of  the  drug  is  deleterious  instead  of  beneficial.  Brown- 
Se"quard  considers  the  appearance  of  acne  to  be  an  indication  that  the 
medicine  has  begun  to  do  its  work,  in  which  opinion  he  is  joined  by  Dr. 
Putnam-Jacobi.6  Voisin7  considers  the  "  point  of  saturation  to  be  indicated 
by  the  anaesthesia  of  the  pharynx  and  nares,  so  that  in  one  case  nausea  is 
not  produced  by  titillation  with  a  spoon,  and  in  the  other  sneezing  and 
weeping  do  not  follow  the  introduction  of  a  straw  into  the  nasal  cavity." 
I  should  consider  the  latter  a  rather  severe  test.  According  to  Danton,8 
the  bromides  act  as  vascular  medicaments,  diminishing  excito-motor 
power.  They  act  on  the  unstriped  muscular  fibre,  producing  local  ana>- 
mia,  and  moderating  excitation  resulting  from  temporary  or  permanent 
congestion.  u  They  are  agents  that  pass  very  rapidly  into  the  blood 
(Ringer),9  and  consequently  their  effects  are  very  immediate,  and  they 
accumulate  till  the  point  of  saturation  is  reached  before  they  are  elimi- 
nated in  anything  like  considerable  amounts."  We  are  all  aware  that 
repeated  and  large  doses  of  these  drugs  are  followed  by  a  most  disagreea- 
ble and  pernicious  state  of  affairs.  Voisin10  has  referred  to  two  forms  of 
bromism,  which  he  has  divided  into  the  slow  and  rapid.  In  the  first  the 
complexion  becomes  muddy,  the  eyes  sunken,  sight  and  hearing  poor,  and 
memory  obscure.  The  patient  cannot  write,  and  cannot  express  himself, 

1  Op.  oit.,  p.  202. 

4  Op.  cit.,  p.  323,  vol.  ii. 

3  Matcria  Modica  and  Therapeutics,  p.  371. 

4  Clinical  Lectures  on  Nervous  Diseases. 

5  Functional  Nervous  Disease,  p.  325. 

6  Oral  communication  before  Am.  Neurological  Association. 

7  Voisin,  Archiv.  de  Medecine,  Jan.  1873. 

8  Danton,  Tlifese  de  Paris,  1874. 

9  Op.  cit.,  p.  91. 

10  Voison,  Archiv.  de  M6decine,  Jan.  1873. 


EPILEPSY.  329 

as  he  forgets  words  ;  thei-e  is  tremulousness.  In  the  other  variety  of  the 
slow  form  there  is  dementia,  or  delirium  with  maniacal  outbursts.  Ataxia 
is  also  a  feature  of  this  variety.  In  the  rapid  form — that  with  which  we 
are  most  familiar — somnolence,  headache,  uncertain  walk,  difficulty  of 
speech,  loss  of  expression,  "  fishiness"  of  the  eyes,  drooling  of  saliva,  etc. 
etc.,  are  the  ordinary  symptoms. 

Various  grades  of  toxaemia,  or  even  a  state  which  Voisin  calls  the 
"  cachexie  bromique,"  and  which  terminates  in  a  typhoid  condition,  may 
result  from  a  reckless  use  of  this  drug. 

As  regards  the  variety  of  bromide,  I  think  the  sodic  is  the  most  reliable 
and  stable,  the  potassic  salt  varying  very  much  in  strength.  The  others 
either  have  a  tendency  to  deliquesce,  or  are  expensive.  It  will  be  advis- 
able to  keep  the  solution  in  a  tight-stoppered  bottle,  and  have  fresh  quan- 
tities put  up  constantly,  as  it  is  very  apt  to  undergo  changes — in  which 
the  bromine  is  evolved.  And  now  a  word  regarding  the  time  of  adminis- 
tration. It  has  been  shown  repeatedly  that  these  salts  are  much  better 
absorbed  when  the  stomach  is  empty.  I  have  found  also  that  a  heavy  dose 
at  night  is  apt  to  do  more  good  than  if  the  amount  prescribed  is  equally 
divided  up  through  the  day.  In  a  great  many  patients  I  have  found  the 
attacks  to  occur  at  the  waking  hour,  and  I  suppose  this  is  due  to  the  sudden 
change  in  the  cerebral  circulation.  A  mild  diffusive  stimulant  has  over- 
come this,  and  in  many  cases  warded  off  the  attack.  I  direct  my  patients 
who  have  their  convulsion  at  this  time  to  keep  a  glass  or  a  small  quantity 
of  spts.  ammonia?  aromaticus  near  at  hand,  to  be  taken  before  rising. 
Cold  douches  to  the  head  are  valuable.  If  the  attacks  be  irregular,  it  will 
be  found  necessary  to  divide  the  dose. 

The  treatment  of  the  disease  in  women  should  be  directed  as  well  to  the 
pelvic  organs.  It  will  be  found  that  the  bromides  will  markedly  affect  the 
flow,  and  relieve  the  pain  or  uneasiness  which  is  connected  with  the  men- 
strual period.  Locally  I  have  found  that  cold  applied  for  a  few  minutes 
daily  over  the  ovaries  will  modify  the  attacks  should  they  be  connected 
with  irritation  of  any  of  the  pelvic  viscera.  The  progress  of  the  disease 
should  be  soon  modified  by  the  doses  I  have  recommended;  and  it  will  be 
seen  by  the  table  condensed  from  that  prepared  by  Dr.  Hollis,1  that  even 
smaller  doses  modified  or  cured  the  majority  of  the  cases  he  cites.  At  the 
Epileptic  and  Paralytic  Hospital,  where  most  of  the  cases  are  the  very 
worst  that  can  be  collected  as  regards  chronicity,  I  find  that  sixty  grains 
a  day  will  cut  short  the  attacks  of  a  great  many  patients,  and  I  have 
cured  a  number  of  private  patients  by  this  method.  Dr.  Hollis'  cases 
were  not  selected,  and  are  evidently  hospital  patients,  like  my  own. 

1  British  Medical  Journal,  July  1,  1876,  p.  4. 


330  BULBAR    DISEASES. 

Analysis  of  Eleven  Cases  of  Epilepsy. 
S.  B.— Sodic  bromide.  P.  B.— Potassic  bromide. 


1 

*3 

•K 

1 

•j 

3 

4 
6 

8 
0 
10 

11 

Sex  and 
age. 

Duration  of 
disease. 

Average 
No.  of 
attacks 
befure 
treatment. 

Maximum      Minimum 
dose.             dose. 

Diminu- 
tion. 

Remarks. 

Main,      15 
Hale,      22 

Male,      2J 

Female,   2 

Female,  18 
Male,      IS 
Female,  11 

Female,  17 
Male,      20 
Male,      13 

Male,      2-< 

Since  birth 
Two  years 

One  year 

IS  months 

One  year 
Five  years 
Five  years 

Several 
months 
19  years 

Two  years 
11  years 

1-2  weekly 
1-2  weekly 

1    or   more 
In   wepk, 
s  >roetime.s 
many  in  a 
day 
1-2  weekly, 
sometimes 
3  in  a  day 
1  in  week 

4  in  week 
2-3  in  week 

Sometimes 
4-  •>  daily 
2-3  weekly 

3  weekly 
1  in  2  weeks 

S.B.  gr.  xx.  S.B.  gr.  xv. 
t.  i  d.            t   i.  d. 

2  in  8  weeks 
1  in2J  w'ks 

None  In  8 
weeks 

None  in  8 
weeks 

None   in   4 
weeks 
None  from  5 
weeks 
1  in  5  w'ks 

N  >ne   after 
trentment 
No  fits   fur 
-  weeks 
1  in  3  w'ks 

1  in  5  w'ks 

Weak  intellect. 

Disease   followed 
sunstroke;  treat- 
ment lasted  three 
months. 
Hard   drinker, 
feeble   intellect  ; 
potassium   salt 
Inert. 

Fits  followed  den- 
tition ;  rickety 
constitution. 
Tuberculous   dis- 

..!-.-. 

No  affection  of 
intellect. 
Followed  a  blow  ; 
subject  to  head- 
ache. 
Has  bitten  tongue 

No  aura. 

Well   developed 
disease,   facies 
epileptica  well 
marked. 
No   fits   since    be- 
ginning of  treat- 
ment. 

S.B.  gr.  xv  

SB.  xxv..     S.B.  gr.  ij. 
P.B.  gr. 

XXX. 

doses 
S.B.  gr.xxx  Gr.  xx. 
S.B.  gr.  xv  

S.B.  gr.  xx.  S.B.  gr.  xv. 
S.B.  gr.  xv  

S.B.  gr.  xl.  S.B.  gr.  xv. 
S.B.  gr.xxv  S.B.  gr.  xv. 

S.B.  gr.  xx  

liy  this  table  it  will  be  seen  that  from  fifteen  to  twenty  grains  of  the 
soilic  salt  were  required  to  immediately  decrease  the  number  of  attacks. 

Ilelow  will  be  found  two  tables.  In  one  are  tabulated  the  interesting 
features  of  twelve  cases  of  epilepsy.  They  are  old  hospital  patients,  and 
had  applied  for  admission  after  outside  treatment  had  l>een  exhausted. 
Kven  here  the  bromides,  in  the  doses  I  have  given,  seem  to  do  much  for 
the  sufferers.  Traumatism  and  actual  insanity  make  the  prognosis  as  bad 
sis  it  well  can  be,  and  treatment  is  simply  palliative.  Large  doses  have 
aggravated  many  of  these  cases. 

The  other  observations  are  selected  from  my  note-book,  and  are  illus- 
trative of  the  efficacy  of  the  dose  I  have  advocated.  liromism  occurred  in 
spite  of  all  I  could  do  in  most  of  them,  though  it  was  a  mild  form  and 
under  control.  The  patients  were  all  of  the  better  class,  and  of  course 
had  all  the  advantages  of  comfortable  homes,  attentive  friends,  substantial 
food  and  good  air,  although  many  of  them  were  inclined  to  over-eating,  as 
in  fact  all  epileptics  are.  In  this  respect  there  is  an  advantage  in  favor 
of  the  poorer  patients,  who  cannot  obtain  rich  food. 


EPILEPSY. 


331 


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BULBAR    DISEASES. 


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REMARKS. 

11.  Br.  for  1  month—  flts  increased. 

B 

or  S.  Br.  attacks  were  3  in  month. 

complications. 

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EPILEPSY.  333 

And  now  regarding  the  large  doses.  If  the  idea  is  to  thoroughly  ruin 
the  patient's  health,  enfeeble  his  mind,  or  perhaps  drive  him  to  an  asylum, 
the  toxic  administration  may  be  indulged  in.  It  is  very  true  that  some- 
times a  rapid  restoration  may  be  brought  about  by  "iron  and  quinine;" 
but  there  are  many  cases  where  the  recovery  is  not  quite  so  complete  as 
one  could  wish  for.  Memory  is  enfeebled,  and  there  is  a  cachexia  which 
remains  for  an  indefinite  time.  A  darker  side  of  the  picture  is  not  always 
displayed  when  brilliant  results  are  detailed.  This  is  the  list  of  demented 
and  those  that  have  died.  My  friend,  Dr.  Janeway,  was  present  at  the 
autopsies  of  two  patients  who  died  brominized,  for  certainly  the  examina- 
tions disclosed  no  other  cause  for  death.  I  myself  have  seen  several 
demented  cases,  and  I  have  no  doubt  others  could  tell  the  same  story.  I 
have  used  the  bromides  in  combination  witl^chloral  hydrate,  and  have 
obtained  the  most  excellent  effects.  Such  good  results  as  diminished  stu- 
por and  eruption  follow  the  administration  of  equal  parts  of  chloral  and 
the  bromide  of  sodium.1 

Belladonna  and  its  alkaloids  are  of  great  value  when  the  seizures  occur 
in  the  daytime,  or  are  of  the  variety  known  as  petit  mal.  I  have  injected 
the  sulphate  of  atropia  in  ^  gr.  doses  beneath  the  skin  at  the  back  of  the 
neck  with  good  effect,  and  have  used  it  in  the  manner  directed  by 
Trousseau.  In  either  way  it  should  be  administered  until  dryness  of  the 
throat  is  obtained,  and  should  be  given  a  patient  trial.  The  property 
possessed  by  belladonna  of  blunting  reflex  susceptibility  assures  it  a  great 
advantage  over  other  methods  of  treatment,  when  there  are  centres  of  irri- 
tation such  as  in  gastric  epilepsy. 

In  ergot  we  have  a  remedy  which  controls  the  cranial  circulation  much 
more  readily  than  any  drug  with  which  I  am  acquainted.  As  the  object  is  to 
diminish  the  congestion  at  the  floor  of  the  fourth  ventricle,  its  combination 
with  the  bromides  greatly  increases  the  action  of  the  latter.  Ergotin  may 
be  given  alone  in  the  form  of  Bonjean's  capsules. 

To  Tyrrell2  belongs  the  credit  of  suggesting  strychnine.  Pie  believes 
that  this  remedy  controls  excitation  of  the  medulla  oblongata.  In  one 
individual  who  averaged  fifty-one  attacks  in  a  month,  the  number  was 
reduced  by  the  strychnine  to  eleven  in  two  years.  Handheld  Jones  does 
not  favor  the  remedy,  nor  do  others,  although  it  has  advocates  in  this 
country.  In  small  doses  it  certainly  does  good ;  but  I  have  found  that  in 
larger  doses  than  ^  gr.,  ter  in  die,  it  rather  aggravates  the  disease. 

Arsenic  is  excellent,  both  for  its  anti-periodic  and  alterative  action,  and 
as  an  agent  to  relieve  the  acne.  Clemens,  of  Frankfort,  has  lately  advo- 
cated the  bromide  of  arsenic,  but  in  such  small  doses  as  to  seem  useless. 
He  claims  for  it  remarkable  virtue  when  the  disease  depends  upon  idiocy, 
and  appears  in  patients  with  deformity  of  the  skull.  He  reports  two 
cures. 

1  While  these  pages  are  going  through  the  press  the  preliminary  report  of  the 
New  York   Therapeutical   Society  confirms  what  I  have  said  in  regard  to  this 
mixture,  which  is  undoubtedly  the  best. 

2  Med.  Times  and  Gazette,  May  and  August,  1867. 


334  BULBAR    DISEASES. 

Where  there  is  an  irregularity  of  heart  action,  sluggish  circulation, 
blueness  or  duskiness  of  the  skin,  I  think  digitalis  is  indicated ;  in  fact,  I 
generally  use  it  in  every  chronic  case.  It  is  a  drug  well  tolerated  by 
epileptics,  who  can  take  it  in  surprisingly  large  doses. 

An  agent  has  been  lately  given  to  the  profession  which  seemed  all  that 
was  needed  at  first,  but  which  I  am  convinced  is  very  much  over-estimated, 
except  as  an  abortant.  I  speak  of  the  amyl  nitrite.  Drs.  Weir  Mitchell, 
Zeigler,  and  Alexander  McBride,  as  well  as  several  foreign  writers,  have 
praised  it,  and  several  cures  have  been  reported.  In  epilepsy  there  seems 
to  be  a  "habit"  (if  I  may  use  the  expression)  or  tendency  to  periodicity. 
Amyl  is  well  adapted  to  stop  this,  as  is  any  other  remedy  of  the  same 
class.  Crichton  Browne  alludes  to  the  effects  of  this  drug  upon  the  stalim 
epilepticits.  His  patient  bad  had  a  great  succession  of  fits,  and  was  ;it 
the  point  of  death;  the  pupils  were  contracted  to  an  intense  degree,  pul-e 
1 16,  temperature  102°,  with  stertorous  breathing.  Voluntary  movements 
and  yawning  were  caused  by  inhalation  of  the  amyl  nitrite,  and  the  pa- 
tient subsequently  raised  his  head,  looked  about  him,  and  recovered.  Dr. 
Browne  relates  ten  other  cases  which  were  seen  with  Dr.  Mierson. 

Dr.  C.  Steketec1  draws  the  following  conclusions  in  regard  to  the  action 
of  this  drug  in  epilepsy: — 

"It  exerts  an  important  influence  where  the  epilepsy  is  due  to  or  con- 
nected with  cerebral  anjemia,  for  the  reason  that  it  '  anticipates  the  attack 
when  there  are  prodromata;  cuts  off  the  attack  when  it  appears;  relie\t  - 
symptoms  due  to  interrupted  innervation  after  the  attack;  and  the  attacks 
become  less  frequent'  "  (? by  the  author).  He  also  considers  it  injurious 
where  the  attacks  are  due  to  cerebral  hyperamia,  for  the  reason  that  they 
last  longer  and  become  more  frequent,  and  when  either  maniacal  or  con- 
vulsive, increase  in  intensity. 

My  own  experience  with  amyl  nitrite  has  clearly  settled  in  my  mind 
the  fact  that  it  lias  great  virtues  in  cutting  short  or  averting  attacks,  but 
that  it  has  no  permanent  influence.  Whether  we  can  or  cannot  make  the 
delicate  distinctions  of  Dr.  Steketec,  future  clinical  experiences  I  think 
must  decide.  Those  who  have  used  it  say  that  it  does  good  in  a  very  lim- 
ited number  of  cases;  and  it  is  a  difficult  task  to  decide  which  are  to  be 
benefited.  I  have  tried  it  in  every  grade  of  epilepsy,  and  find  in  some  of 
the  worst  cases,  where  the  fits  occur  all  through  the  day  with  very  slight 
intervals,  and  even  where  there  is  time  enough  to  be  prepared,  that  it  is 
often  of  no  avail.  It  may  be  given  inclosed  in  the  little  glass  capsules 
invented  by  Dr.  McBride,  of  New  York,  for  hospital  use,  and  for  patients 
who  are  not  intelligent,  in  alcoholic  solution. 

I  may  be  pardoned  for  bringing  another  remedy  to  the  notice  of  the 
profession,  and  one  that  has  never  been  used  for  this  purpose.  I  allude 
to  tri-nitro-glycerine.  Its  reputation  is  almost  enough  to  intimidate  the 
patient,  but  it  is  as  powerful  a  medicinal  agent  as  it  is  an  explosive.  The 

1  Thesis  abstracted  by  Chicago  Journal  of  Nervous  and  Mental  Disease,  April, 
1874,  p.  260. 


EPILEPSY.  335 

tenth  part  of  a  drop  touched  to  the  tongue  is  sufficient  in  a  space  of  time 
which  is  almost  inappreciable  to  produce  a  rapid  cerebral  hyperaemia. 
The  face  is  flushed,  the  eyes  become  bright,  and  the  temporal  vessels 
throb,  while  at  the  same  time  there  are  marked  sensations  of  fulness. 
It  produces  more  lasting  congestion  than  does  amyl  nitrite,  is  much  safer, 
and  I  have  found  it  to  act  better  as  an  abortant  than  the  latter.  Any 
good  pharmacist  can  prepare  a  solution  containing  one  drop  to  ten  of  alco- 
hol. This  can  be  further  diluted,  so  that  ten  drops  of  alcohol  shall  contain 
one-tenth  of  a  drop  of  the  nitro-glycerine.  It  may  be  kept  safe  in  this 
way,  for  alcohol  prevents  its  explosion.  A  dose  of  a  tenth  of  a  drop  is 
sufficient  in  the  majority  of  cases. 

Last  of  all,  it  seems  almost  unnecessary  for  me  to  direct  attention  to 
that  most  familiar  remedy,  cod-liver  oil,  which  is  so  valuable  in  all  nervous 
diseases. 

Anstie  treated  a  number  of  cases  by  cod-liver  oil  alone,  and  cured  seven 
out  of  twenty  patients  put  upon  this  plan  of  treatment  alone.  In  all  cases 
I  am  convinced  that  it  is  a  valuable  remedy  which  is  not  appreciated  as  it 
should  be.  I  have  witnessed  its  great  virtues  when  the  bromide  cachexia 
was  profound,  and  believe  that  it  should  always  be  used  in  delicate  sub- 
jects. Picrotoxin,  a  remedy  recently  brought  forward,  I  have  tried,  and 
consider  valueless. 

The  subjects  of  diet  and  personal  habits  are  very  important  ones — par- 
ticularly as  the  stomach  is  so  often  the  seat  of  irritations  which  are  trans- 
mitted to  the  over-active  centres.  Beyond  the  question  of  over-eating,  it 
has  been  found  that  a  vegetable  diet  is  better  suited  to  this  class  of 
patients.  Mierson,  in  one  of  the  late  volumes  of  the  West  Hiding  Reports, 
publishes  cases,  and  makes  comparisons  between  those  epileptics  placed 
upon  a  meat  and  those  placed  upon  a  vegetable  diet.  The  results  pointed 
to  the  superiority  of  the  latter.  As  the  greater  number  of  epileptics  have 
inordinate  appetites,  the  diet  should  be  strictly  regulated. 

It  is  a  good  plan,  I  think,  to  combine  the  remedies  I  have  alluded  to ; 
and  I  take  the  liberty  of  presenting  a  prescription  I  have  used  for  several 
years  : — 

R.   Strychnite  sulph.  gr.  j. 
Fl.  ext.  ergota?,  §iss. 
Sol.  potass,  arsenit.  gij. 
Sodii  bromidi,  .^iss. 
Tr.  digitalis,  giij. 
Aquae  menth.  pip.  ad  ^iv. — M. 
Sig. — A  toaspoonful  before  eating,  in  a  half  tumblerful  of  water. 

If  the  attacks  be  of  the  form  known  us  petit  mat,  I  think  either  ergot  or 
belladonna  is  our  best  agent.  With  either  form  of  treatment  it  may  be 
found  often  necessary  to  use  auxiliary  general  treatment.  The  syrup  of 
the  combined  phosphates,  or  the  syrup  of  the  lacto-phosphate  of  lime,  is 
a  good  adjunct ;  and  salt  baths,  cold  head  douches,  regular  food,  early 
hours,  and  the  breaking  off  of  bad  habits,  will  often  cure  the  disease,  even 
when  it  has  lasted  many  years. 


336  BULBAR    DISEASES. 

As  ft  last  resort,  should  continued  medication  prove  useless,  the  actual 
cautery  or  a  deep  seton  at  the  back  of  the  neck  will  occasionally  arrest 
these  bad  cases. 

A  variety  of  other  remedies  have  been  suggested  (and  the  list  of  drugs 
alone  would  fill  several  pages  such  as  this),  but  as  most  of  them  have  been 
found  inefficacious,  I  do  not  think  it  worth  while  to  further  weary  the 
patience  of  my  readers.  Galvanism,  which  has  been  recommended  by 
Hammond,  I  find  to  have  but  little  value. 


BULBAR  PARALYSIS. 

Synonyms Glosso-labio-laryngeal  paralysis  (Hammond)  ;  Glosso- 

laryngeal  paralysis  (Trousseau). 

In  the  year  1841  Duchenne1  first  called  attention  to  a  peculiar  group  of 
symptoms  which  were  connected  with  progressive  degeneration  of  the 
medulla  oblongata;  and  some  years  later  Trousseau2  noticed  it  in  his  admi- 
rable lectures,  and  presented  several  cases  reported  by  Davaine,8  long 
before  Duchenne's  observations  were  published,  but  which  were  before 
considered  to  be  examples  of  double  facial  palsy.  Hughlings  Jackson,* 
Dumesnil,5  Charcot,6  and  Joffroy,  Hammond,7  and  lately  Dowse,8  have 
added  new  facts  to  the  literature  of  the  subject. 

The  condition  under  discussion  may  be  described  as  a  disease  character- 
ized by  gradual  loss  of  functions  of  parts  supplied  by  the  nerves  taking  their 
origin  from  the  medulla,  though  the  fifth  nerve  is  rarely  affected. 

It  may  be  the  result  of  morbid  changes  which  are  limited  to  the  floor  of 
the  fourth  ventricle  ;  or,  as  this  region  may  be  the  chance  site  of  sclen»i>. 
which  atfrets  other  parts  as  well.  Such  may  be  the  lesion,  whether 
"  pseudo-bulbar  paralysis"  (the  result  of  arterial  occlusion),  sclerosis,  or 
glosso-labio-laryngeal  paralysis  exists ;  the  special  symptoms  are  alike,  and 
they  appear  one  after  another  as  the  different  nerves  are  involved. 

Symptoms — The  earliest  expression  of  the  disease  is  a  certain  loss 
of  power  of  the  lips  ;  the  lower  lip  especially.  If  the  individual  attempts 
to  whistle,  his  efforts  may  be  unsuccessful,  and  the  lower  lip  hangs  so  that 
the  mucous  surface  is  largely  exposed.  The  tongue  next  follows,  and  its 
protrusion  by  the  patient  is  a  matter  of  difficulty.  The  individual  is  un- 
able to  bring  the  tip  in  contact  with  the  roof  of  the  mouth,  and  incompe- 
tent to  use  it  in  the  formation  of  certain  consonants  (the  linguals).  When 
he  tries  to  speak  or  read  aloud  he  finds  great  difficulty  in  pronouncing 

1  Op.  fit.,  2 me  edit. 

2  Lectures  on  Clinical  Medicine,  trans.,  vol.  i.  p.  908. 

3  Quoted  by  Trousseau,  vol.  i.  p.  909. 

4  Philosophical  Transaction:',  part  i.,  1868. 
s  (iaz.  Hebdomadaire,  Juin,  1859,  p.  390. 

6  Archiv.  do  Physiol.,  torn,  in.,  1870,  p.  247. 

7  Diseases  of  Nervous  System,  p.  502  et  seq. 

8  Brit.  Med.  Journ.,  Nov.  4  and  11,  1876. 


BULBAB    PARALYSIS.  337 

words  containing  the  letters  1,  n,  c,  d,  g,  h,  j,  t,  w ;  and  in  one  of  Trous- 
seau's cases  the  patient  could  not  utter  any  letter  but  a. 

He  may  remain  in  this  condition  for  some  time — say  for  a  year  or  two, 
when  the  tongue  and  lips  become  more  extensively  affected  ;  and  not  only 
are  acts  of  a  voluntary  character  impossible,  but  the  automatic  movements 
of  the  tongue  become  almost  totally  embarrassed.  The  use  of  this  organ 
in  the  management  of  food  during  mastication  and  deglutition  is  much 
impaired,  and  particles  of  food  become  lodged  between  the  teeth  and  the 
gums  and  cheek. 

The  patient's  mouth  is  generally  open,  so  that  his  teeth  are  exposed,  and 
from  either  side,  trickles  a  glairy  stream  of  saliva.  Next  he  cannot  arti- 
culate the  labials,  and  consequently  his  speech  becomes  worse  than  ever. 

His  face  wears  an  inane  expression,  and  he  is  apt  to  attract  the  atten- 
tion of  the  people  in  the  street  by  his  open  mouth  and  silly  appearance. 
The  condition  of  the  tongue  has  been  noted  by  Dowse  ;  its  papilla?  become 
atrophied,  and  the  surface  very  smooth.  I  have  noticed  that  there  is  no 
loss  of  the  sense  of  taste  at  any  time. 

The  palate  next  becomes  the  seat  of  the  paralysis,  and  the  pharyngeal 
muscles  are  so  weak  that  deglutition  is  at  first  difficult,  and  finally  impos- 
sible.1 Fluids  are  especially  troublesome  to  swallow,  and  are  apt  to  be 
regurgitated  through  the  nares,  and  the  voice  becomes  nasal  and  metallic 
as  the  upper  part  of  the  vocal  apparatus  becomes  involved. 

The  facial  expression,  always  a  marked  feature  of  the  disease,  is  now 
very  pitiable.  The  tongue  lies  in  the  bottom  of  the  mouth  utterly 
devoid  of  power,  so  that  the  patient  cannot  protrude  it,  and  it  becomes 
useless  for  all  purposes.  If  the  posterior  wall  of  the  pharynx  be  irritated, 
there  is  none  of  the  reflex  response  which  is  so  marked  in  the  normal 
state,  but  only  pain  is  produced.  Such  was  the  condition  of  affairs  noticed 
in  one  of  Dr.  Dowse's  patients. 

The  epiglottis  does  not  cover  the  larynx  ;  and  there  is  a  tendency  to 
choking  from  the  accidental  introduction  of  food,  so  that  eating  becomes 
a  dangerous  undertaking.  The  voice  grows  very  weak,  and  the  sufferer 
can  no  longer  even  make  the  almost  unintelligible  sounds  which  charac- 
terized the  early  stages  of  his  disease. 

His  breathing  now  becomes  very  irregular,  his  inspirations  are  quite 
slow  and  shallow,  and  he  sinks  from  exhaustion  due  to  insufficient  nourish- 
ment and  becomes  a  mere  wreck,  dragging  himself  about,  and  looking  for- 
ward to  death  as  something  which  alone  is  to  bring  relief.  As  the  pneumo- 
gastric  becomes  more  and  more  involved,  the  respiration  undergoes  changes 
which  result  in  asphyxia. 

For  some  time  before  the  end,  his  sufferings  grow  intense.  Mucus 
collects  in  the  bronchi,  which  he  is  unable  to  remove  by  coughing,  and 
lie  sits  in  his  chair  with  a  feeling  of  greater  security  than  when  lying 


1   Sometimes  the  bolus  of  food  finds  its  way  into  the  larynx  and  suffocates  the 
patient. 

22 


338  BULBAR    DISEASES. 

down,  for  in  the  supine  position  the  saliva  finds  its  way  into  the  larynx, 
and  produces  suffocation.  Loss  of  consciousness  or  mental  impairment 
is  never  a  symptom  of  the  disease  unless  it  be  of  the  complicated  form. 

The  following  interesting  case  was  reported  recently  by  Dr.  A.  H. 
Smith,1  of  this  city  : — 

The  subject  was  a  clergyman,  aged  sixty-one  years.  About  fifteen  years 
ago,  after  prolonged  and  severe  exercise  of  the  voice  in  preaching,  he  be- 
came hoarse,  and  ultimately  his  voice  failed  so  that  he  could  speak  only 
in  a  whisper. 

After  the  lapse  of  a  year  he  gradually  regained  the  use  of  the  larynx, 
but  as  he  did  so  he  became  sensible  of  an  imperfection  in  his  enunciation 
of  certain  syllables,  especially  those  containing  the  letters  p,  t,  d,  s,  etc. 
This  difficulty  has  increased  until  now  the  power  of  uttering  the  labial 
and  lingual  sounds  is  almost  entirely  lost. 

Later  a  difficulty  in  swallowing  was  gradually  developed,  which  has 
reached  such  a  degree  that  only  warm  fluids  can  be  taken,  and  these  with 
great  care  and  hesitation,  as  they  are  apt  to  cause  strangling,  and  to  re- 
turn through  the  nose.  Mucus  accumulates  in  the  fauces,  which  he  has 
great  difficulty  in  getting  rid  of,  and  which  causes  a  sense  of  strangulation. 

He  finds  that  the  movements  of  the  tongue  are  very  much  restricted, 
and  he  has  not  the  full  control  of  his  lips. 

His  sight,  taste,  and  smell  are  as  perfect  as  is  usual  in  persons  of  his 
age.  The  sense  of  touch,  even  in  the  paralyzed  parts,  is  not  impaired. 

He  feels  much  less  distress  when  the  weather  is  warm,  and  dreads  the 
approach  of  each  winter. 

Such  is  the  account  which  the  patient — a  very  intelligent  man — gave 
of  himself.  As  to  the  objective  appearances,  the  patient  moved  slowly 
and  feebly,  but  this  was  evidently  the  result  of  mere  debility.  The  next 
notable  thing  at  a  cursory  glance  was  the  expression  of  his  mouth.  The 
orbicularis  muscle  was  entirely  paralyzed,  permitting  the  lower  lip  to  fall 
away  from  the  upper,  and  to  become  partly  everted.  There  was  also 
relaxation  and  eversion  of  the  upper  lip  from  the  same  cause.  The  leva- 
tores  menti  and  the  depressores  ang.  oris  were  not  involved  in  the  para- 
lysis, and  by  their  aid  the  patient  was  able  to  bring  the  lips  into  contact ; 
but  when  so  approximated  they  projected  forward,  leaving  a  space  be- 
tween them  and  the  teeth,  and  giving  a  very  peculiar  expression  to  the 
face. 

When  the  month  was  opened  the  movements  of  the  tongue  were  ob- 
served to  be  very  slow  and  very  much  restricted.  The  tip  could  not  be 
turned  upward  to  touch  the  roof  of  the  mouth,  nor  backward  beyond  the 
bicuspid  teeth.  The  tongue  was  not  notably  changed  in  shape  or  size. 

All  the  muscles  of  the  soft  palate,  including  the  palato-pharyngi  and 
palato-glossi,  were  paralyzed,  so  that  when  the  head  was  thrown  back- 
ward the  relaxed  velum  fell  of  its  own  weight  against  the  posterior  wall 
of  the  pharynx.  The  finger  carried  into  the  fauces  produced  scarcely  any 
local  reflex  action,  showing  that  the  constrictors  were  complicated ;  but 
sensation  was  perfect,  and  the  reflex  action  of  the  stomach  seemed  unim- 
paired, efforts  at  vomiting  being  readily  excited. 

There   was  a   very  profuse   secretion  of  mucus  from   the  larynx  and 


.  Record,  Nov.  24,  1877. 


BIJLBAR    PARALYSIS.  339 

pharynx,  which  was  gotten  rid  of  with  the  utmost  difficulty.  There  being 
perfect  inability  to  contract  the  cavity  of  the  pharynx,  the  air  which  was 
forced  from  the  larynx  in  the  act  of  hawking  escaped  into  a  great  loose 
bag,  instead  of  into  a  narrow,  firm  passage,  and  thus  it  failed  to  drive  the 
mucus  before  it.  The  paralysis  of  the  soft  palate  added  to  the  difficulty, 
for  when  by  great  labor  a  portion  of  mucus  was  coughed  up  into  the  back 
part  of  the  mouth,  the  non-closure  of  the  isthmus  faucium  permitted  it  to 
fall  back  again  upon  the  larynx. 

Examination  with  the  mirror  showed  that  the  laryngeal  muscles  re- 
tained their  activity,  and  the  cords,  with  the  exception  of  slight  hyperae- 
mia,  were  normal.  The  respiratory  muscles  were  as  yet  unimpaired. 

In  this  case  it  is  not  probable  that  the  loss  of  voice,  which  occurred  in 
the  early  stage  of  the  disease,  was  owing  to  a  central  lesion,  since,  after  a 
your  had  passed,  the  larynx  gradually  regained  its  power.  Moreover, 
laryngeal  paralysis  of  bulbar  origin  does  not  usually  occur  in  this  associa- 
tion until  after  the  paralysis  of  the  lips,  tongue,  and  soft  palate  has  become 
'well-marked.  It  is  more  than  probable  that  the  aphonia  was  the  result  of 
a  catarrhal  affection,  and  that  if  life  continues  long  enough  there  will  be 
a  return,  but  this  time  from  advancing  changes  in  the  medulla. 

The  greater  ease  in  swallowing  warm  fluids  is  characteristic  of  clyspha- 
gia  from  almost  any  cause.  Thus  it  is  observed  in  both  organic  and  spas- 
modic stricture  of  the  oesophagus,  and  also  when  dysphagia  results  from 
the  pressure  of  a  tumor. 

Dowse1  considers  the  disease  to  be  either  progressive,  stationary,  or  re- 
trogressive, and  if  it  were  not  for  the  single  case  of  the  last  variety,  which  he 
publishes,  I  should  not  be  prepared  to  accept  the  two  latter  divisions. 
This  he  calls  reflex  bulbar  paralysis.  His  patient,  a  woman  aged  59, 
suffered  from  Bright's  disease  and  inflammation  of  the  maxillary  and 
parotid  glands.  After  her  recovery  from  the  last-mentioned  condition, 
there  was  paralysis  of  the  hypoglossal,  facial,  and  spinal  accessory  nerves, 
as  well  as  the  third  division  of  the  fifth.  The  vocal  cords  acted  feebly, 
and  she  could  scarce  speak  in  a  whisper,  being  able  to  pronounce  only  the 
linguals  r  and  s,  and  could  not  protrude  her  tongue ;  food  lodged  in  the 
cheeks ;  saliva  dribbled  from  the  mouth ;  she  was  unable  to  blow  out  a 
candle,  while  deglutition  was  interfered  with  to  some  extent.  Strange  to 
say,  there  has  been  improvement.  It  would  be  well,  however,  if  Dr. 
Dowse  had  allowed  a  longer  time  to  elapse  before  coming  to  a  conclusion 
in  regard  to  the  retrogressive  character  of  the  disease  in  this  instance,  for 
the  parotitis  may  have  been  simply  a  coincidence.  I  am  inclined  to  think 
that  the  history  of  any  genuine  case  thus  far  reported  has  shown  a  ten- 
dency to  progressive  decline  which,  though  delayed  in  some  instances,  has 
nevertheless  steadily  advanced  to  a  fatal  termination. 

Causes The  disease  is  one  of  middle  age,  and  attacks  men  more 

often  than  women.  It  is  usually  the  result  of  syphilis,  and  sometimes  fol- 
lows exposure  and  mental  worry.  Dowse  considers  the  causes  of  the 
peripheral  symptoms  to  be  the  following : — 

1  Brit.  Med.  Journ.,  Nov.  11,  1876,  p.  615. 


340  BULBAR    DISEASES. 

Direct. 

1.   Progressive  interstitial  neuritis. 
'2.  Thrombosis. 

3.  Hemorrhage.          ^ 

4.  Morbid  growths.      -    Rare. 
").   Vascular  spasm.    ) 

Indirect. 

1.  Reflex  action  from  peripheral  irritation. 

2.  Inhibition  from  shock  to  central  cerebral  ganglia. 

Morbid  Anatomy  and  Pathology. — Trousseau's  autopsies  re- 
vealed  induration  of  the  medulla,  atrophy  of  the  roots  of  the  hypOgkxiiMd 
and  spinal  accessory  nerves,  thickening,  and  gray  discoloration  of  the  dura 
mater  on  a  level  with  the  medulla,  which  extended  as  far  down  as  the 
roots  of  the  fourth  cervical  pair.  "  This  thickening  was  due  to  a  consid- 
erable increase  in  the  amount  of  fibres  of  connective  and  fibre-elastic  tis- 
sue, and  seemed  to  result  from  a  chronic  congestive  process,  as  shown  by 
the  great  number  of  capillaries  and  of  deposits  of  ha-matin  external  to 
them.  The  motor  nerve-roots  of  many  cervical  nerves  were  found  thinner 
than  they  should  be  from  disappearance  of  nerve-tubes.  The  fifth  and 
glosso-pharyngeal  nerve-roots  were  healthy,  and  the  muscular  tissue  of  the 
paralyzed  parts  was  found  to  be  normal." 

Dumenil  published  a  case  which  was  probably  progressive  atrophy,  but 
some  of  the  symptoms  were  those  of  the  disease  under  consideration.  In 
this  case  there  was  extensive  atrophy  of  the  roots  of  the  hypoglossal, 
pnemuogastrie,  and  facial  nerves,  as  well  as  a  great  many  other  changes. 

Fox1  considers  an  absolute  or  partial  disappearance  of  the  nerve-tubes, 
witli  preservation  of  the  neurilemrna  at  the  nerve-roots,  to  be  a  constant 
lesion;  and  Wilks9  found  the  roots  of  the  hypoglossal  and  spinal  accessory 
nerves  had  undergone  atrophy,  and  become  reduced  to  "  little  thin 
gelatinous  threads." 

Sclerosis  may  occasionally  involve  the  medulla,  and  produce  symptoms 
characteristic  of  loss  of  function  in  the  nerves  to  which  I  have  alluded. 

Chareot*  gives,  among  other  cases,  one  that  involved  the  medulla  ex- 
tensively. A  patient  of  his  presented,  besides  the  ordinary  symptoms  of 
disseminated  sclerosis,  three  months  afterward,  evidences  of  invasion  of 
the  pneumogastric  and  hypoglossal  nerve-roots.  There  were  dyspnoea  and 
dysphagia.  The  patient  was  obliged  to  eat  more  slowly ;  and  oftentimes 
the  food  was  regurgitated  through  the  nostrils.  Death  followed  in  about 
six  weeks  afterwards,  and  was  preceded  by  asphyxia. 

The  autopsy  revealed  the  following  state  of  the  nervous  centres  :  A 
section  made  one  centimetre  below  the  protuberance,  at  the  point  of  origin 

1  Op.  cit.,  p.  -234.  2  Guy's  Hosp.  Rep.,  vol.  xv. 

3  LeQons  sur  leg  maladies  du  systeme  nerveux,  Paris,  1872-73.  Pr6mifere 
partie,  p.  234. 


BULBAR    PARALYSIS.  341 

of  the  trigeminus,  disclosed  a  point  of  sclerosis.  Other  transverse  sections 
were  made  at  the  smaller  part  of  the  olivary  bodies,  and  a  sclerosed  patch 
was  discovered.  Another  patch  was  seen  at  the  root  of  the  pneumogastric. 
Examination  by  the  microscope  revealed  a  number  of  broken  nerve-tubes 
and  broken-down  cells  at  the  nuclei  of  the  hypoglossal,  and  traces  of  irri- 
tation in  the  white  substance  of  Schwann  in  the  pneumogastric  fibres. 
The  pharynx  and  larynx  were  healthy. 

The  observations  of  Lockhart  Clarke  have  shown  the  intimate  relation- 
ship of  the  nuclei  of  the  important  cranial  nerves  which  become  affected 
in  bulbar  paralysis.  There  is  a  set  of  nerve-cells  common  to  these  nerves, 
and  disease  of  the  nuclei  of  one  nerve  is  very  likely  to  extend  to  others  of 
the  group,  so  that  ultimately  there  is  a  general  invasion,  which  is  bilateral 
and  never  one-sided. 

The  destructive  process  is  probably  myelitis,  as  Leyden  has  suggested, 
and  disappearance  of  the  motor-cells  is  the  direct  cause  of  the  paralysis. 

It  is  a  curious  fact  that  the  sixth  nerve  invariably  escapes  when  we 
remember  that  it  arises  from  a  common  nucleus  with  the  seventh,  as 
demonstrated  by  Lockhart  Clarke  and  Stilling.  In  regard  to  the  partial 
paralysis  of  the  facial  as  an  early  symptom,  and  the  subsequent  increase 
in  the  area  paralyzed,  we  must  remember  Romberg's  statement  that  in 
organic  brain-disease  the  entire  distribution  is  not  affected,  but  that  the 
fibres  involved  are  those  that  supply  the  muscles  of  the  upper  lip  and  alae 
of  the  nose;  and  this  is  an  important  point  in  the  diagnosis  from  peripheral 
paralysis ;  and  Dowse  calls  to  mind  the  fact  that  bilateral  paralysis  of  the 
muscles  supplied  by  the  facial  is  connected  with  lesion  at  the  root  of  the 
nerve. 

The  aphonia  may  result,  according  to  Dumenil,  either  from  paralysis 
of  the  thoracic  muscles,  or  of  those  of  the  larynx.  The  ptyalism  I  am 
inclined  to  ascribe,  in  the  later  stages,  to  paralysis  of  the  chorda  tympani, 
but  agree  with  Hammond  that  the  accumulation  of  saliva  in  the  first  stage 
is  due  more  to  the  patient's  inability  to  swallow  it  than  to  anything  else. 
Respiratory  troubles  may  be  due  to  paralysis  of  the  pneumogastric  and 
its  motor,  the  spinal  accessory. 

Dowse  has  divided  the  disease  into  three  stages  as  regards  the  difficulty 
of  swallowing,  the  first  of  which  is  connected  with  paralysis  of  the  hypo- 
glossal  ;  the  second  with  paralysis  of  the  motor  branches  of  the  glosso- 
pharyngeal ;  and  the  third  with  paralysis  of  the  spinal  accessory. 

Voisin,  in  speaking  of  the  alterations  in  speech,  defines  them  into  stut- 
tering, drawling,  hesitation,  jabbering,  stammering,  and  quavering.  The 
first  three  are  due  to  lesions  of  the  nerve-tracts  which  pass  from  the  anterior 
cortex  to  the  medulla  oblongata,  and  which  traverse  the  corpora  striata,. 
crura  ccrebri,  and  pons,  and  are  connected  with  disturbances  of  will. 
The  other  three  have  no  such  origin,  but  depend  upon  incoordination  of 
the  muscles  supplied  by  the  hypoglossal,  facial,  and  glosso-pharyngeal 
nerves. 

Diagnosis Facial  palsy,  general  paralysis  of  the  insane,  progressive 


342  BULBAE    DISEASES. 

muscular  atrophy  and  diphtheritic  paralysis  may  suggest  themselves,  and 
some  are  rather  difficult  to  exclude : — 

1.  Facial  palsy  may  be  suggested,  but  as  this  disease  is  of  sudden  origin, 
and  affects  other  muscles  than  those  about  the  mouth,  there  need  be  no 
reason  to  confound  it  with  bulbar  paralysis. 

2.  The  early  symptoms  of  general  paralysis  of  the  insane  somewhat 
resemble  the  initial  symptoms  of  the  disease  of  which  we  are  speaking. 
There  is  tremor  of  the  tongue,  however,  in  addition  to  the  embarrassment 
of  speech ;  and  subsequent  psychical  symptoms  make  the  diagnosis  clear. 

3.  Progressive  muscular  atrophy  rarely  attacks  the  tongue  primarily, 
and  only  one  case  has  been  reported  (by  Charcot)  where  there  were  any 
bulbiir  symptoms.     The  subsequent  atrophy  of  other  muscles  will  dispel 
any  doubts  the  observer  may  have.     The  affection  of  the  medulla  is  ordi- 
narily a  final  result  of  the  extension  of  the  central  disease  in  progressive 
muscular  atrophy. 

4.  Diphtheritic  paralysis  is  symptomatized  by  initial  paresis  of  the  mus- 
cles of  the  pharynx,  and  the  tongue  is  seldom  involved.     A  previous  his- 
tory of  diphtheria  will  confirm  the  cause  of  the  paralysis,  should  there  be 
a  suspicion. 

Prognosis. — As  I  have  said,  Dowse  believes  that  there  are  forms  of 
the  disease  which  may  bo  cured,  viz.,  the  stationary  and  the  retrogressive, 
I  cannot  believe  that,  when  once  affected  by  inflammatory  disease,  such 
extensive  alteration  and  such  decided  symptoms  as  he  mentions  can  ever 
be  removed. 

The  histories  of  the  cases  reported  by  the  several  observers  already 
mentioned  certainly  offer  a  gloomy  prospect  and  little  encouragement  for 
the  victim.  The  only  case  reported  as  actually  cured  was  that  of  Cheadle,1 
and  from  the  pain,  visual  trouble,  and  unilateral  paralysis,  it  is  improbable 
that  the  case  was  one  of  genuine  bulbar  paralysis. 

Treatment. — Nothing  has  been  done  which  has  resulted  in  any 
decided  improvement.  Hammond*  relates  a  case  which  was  somewhat 
benefited  by  faradization,  but  I  am  sorry  to  say  that  electricity  did  no  good 
in  the  one  case  I  have  treated.  Dowse  recommends  cod-liver  oil,  iron, 
and  phosphorus. 

1  Glosso-labio-laryngfal  Paralysis,  St.  George's  Hosp.  Reports,  vol.  v.,  1871, 
]>.  i^.'J. 

8  Up.  cit.,  p.  518. 


CEREBRO-SPINAL    MENINGITIS.  343 


CHAPTER    XIII. 

CEREBRO-SPINAL  DISEASES. 

CEREBRO-SPINAL  MENINGITIS. 

Synonyms — Spotted  fever ;  Me'ningite  foudroyante ;  Head  pleu- 
risy ;  Myelitis  petechialis ;  Cerebral  or  Cerebro-spinal  typhus ;  Menin- 
gite  cerebro-spinale  ;  Fivere  cerebro-spinale,  etc. 

Definition — A  disease  characterized  by  inflammation  of  the  meninges 
of  the  brain  and  cord,  symptomatized  by  pain,  tetanic  spasms,  and  herpetic 
eruptions,  and  occurring  in  an  epidemic  form. 

This  most  terrible  disease  has  of  late  years  received  a  great  deal  of  atten- 
tion at  the  hands  of  German  and  French  writers.  Niemeyer1  was  one  of 
the  first  of  the  former  to  direct  attention  to  the  disease  ;  while  in  France 
Broussais  and  others  contributed  extensively  to  the  literature  of  the  sub- 
ject. There  is  no  doubt  as  to  the  antiquity  of  the  disease,  for  among  the 
writings  of  Hippocrates  a  nearly  perfect  description  of  the  malady  is  to  be 
found.  In  our  own  country  the  epidemic  character  of  the  affection  was 
noted  by  several  of  the  older  authors,  among  them  North2  (1811),  Gallup3 
(1815),  and  Minor*  (1823),  and  their  contemporaries.  Outbreaks  occurred 
at  Medfield,  Mass.,  Litchfield  Co.,  Conn.,  and  at  various  points  in  the 
Eastern  and  Middle  States  during  the  early  part  of  the  present  century. 
Clymer,5  Jones,6  and  others  have  since  written  exhaustively  on  the  subject. 

Cerebro-spinal  meningitis  is  certainly  an  irregular  disease ;  it  is  not 
contagious,  and  it  is  influenced  seemingly  in  no  way  by  climate,  origin,  or 
soil. 

Symptoms The  appearance  of  symptoms  is  usually  quite  sudden, 

and  their  course  is  remarkably  rapid  and  ordinarily  tends  to  a  fatal  termi- 
nation. In  exceptional  cases  pain  in  the  back,  headache,  vomiting,  or 
malaise  may  constitute  a  premonitory  stage,  which  lasts  a  few  hours  ;  but 
usually  there  is  no  such  delay.  A  severe  rigor,  an  attack  of  vomiting 
which  is  followed  by  headache  of  an  intense  description,  and  an  elevation 
in  pulse  and  temperature  mark  the  commencement  of  the  trouble.  The 
child  may  present  these  symptoms,  and  in  addition  another  symptom 

1  Treatise  referred  to  in  Niemeyer's  Text-Book  of  Prac.  Mod.,  vol.  ii.  p.  218. 

2  Treatise  on  a  Malignant  Epidemic,  etc.,  1811. 

3  Sketches  of  Epidemical  Diseases,  etc.,  1815. 

4  Essays  on  Fevers  and  other  Medical  Subjects,  Middleton,  Conn.,  1828. 

5  Aitkcn's  Science  and  Practice  of  Medicine,  pp.  492-505,  3d  Amer.  edit. 

6  Mod.  and  Surg.  Memoirs,  pp.  412-507. 


344  CEREBRO-SPINAL    DISEASES. 

which  is  invariably  patbognotnonic.  77ie  head  is  drawn  backwards  and 
doicmcards,  and  the  muscles  at  the  back  of  the  neck  are  rigidly  con- 
tracted. At  the  same  time  the  pupils  are  contracted.  The  child  moan- 
constantly,  and  is  restless ;  this  is  an  early  symptom,  and  may  appear  at 
the  end  of  twenty-four  hours,  and  be  the  first  to  attract  our  attention. 

The  pulse  is  now  quite  rapid,  and  may  beat  100  to  120  per  minute. 
The  pain  meanwhile  increases,  and  affects  the  head  as  well  as  the  entire 
length  of  the  spine,  and  is  increased  by  pressure.  Just  as  in  other  forms 
of  meningitis,  the  movements  made  by  the  patient  aggravate  his  suffering, 
and  he  usually  strives  to  keep  quiet.  He  is  conscious  for  the  first  two  or 
three  days  should  he  live  so  long,  but  at  the  end  of  this  time  he  loses  his 
intelligence  after  first  growing  delirious.  The  pulse,  temperature,  and 
respiration  are  increased.  The  former  sometimes  beats  130  per  minute, 
while  the  thermometer  may  indicate  an  advance  to  104°,  but  it  usually 
remains  at  about  100°.  At  an  early  period  crops  of  herpes  appear  upon 
the  face  and  limbs,  and  the  skin  is  hyperaesthetic,  and  the  patient  cannot 
bear  handling.  After  the  first  ninety-six  hours  the  convulsions  succeed 
the  primary  rigidity.  Opisthotonos  or  other  tetanic  contractions  make  their 
appearance.  Stupor  follows,  and  he  dies  in  a  condition  of  coma ;  and 
according  to  Niemeyer  death  takes  place  with  symptoms  of  cedema  of 
the  lungs.  The  bowels  are  constipated  during  the  entire  disease,  and 
during  the  later  stages  the  patient  has  involuntary  discharges  of  urine. 

The  above  description  is  of  an  ordinary  case.  There  are  great  varia- 
tions, and  either  death  may  take  place  in  a  few  hours,  or  there  may  be  a 
tardy  convalescence  accompanied  by  structural  changes  of  a  very  serious 
nature.  The  course  of  the  disease  may  open  with  chill  followed  by  rapid 
convulsions  and  coma,  when  the  patient  may  die  in  less  than  twenty-four 
hours. 

In  other  cases,  after  the  subsidence  of  the  acute  symptoms,  which  may 
last  for  a  week  or  two,  convalescence  takes  place,  attended  by  headache 
and  muscular  contractions,  which  continue  for  some  time.  Deafness  very 
often  results;  and  I  have  several  times  met  with  total  loss  of  vision,  and 
paralysis  of  some  of  the  facial  muscles.  In  one  case  brought  to  me  from 
the  interior  of  the  State,  there  was  rigid  contraction  of  the  muscles  at  the 
back  of  the  neck  ;  and  in  another,  seen  with  Dr.  F.  II.  Kankin,  now  of 
Newport,  besides  ptosis  and  paralysis  of  the  pharynx,  there  was  an  otor- 
rha>a,  with  extensive  middle-ear  disease.  This  patient  was  quite  an  im- 
becile, intellectual  impairment  lasting  after  the  subsidence  of  the  acute 
stages.  One  of  these  chronic  cases  has  been  under  observation  for  several 
years,  but  I  have  been  unable  to  effect  more  than  trifling  improvement. 

Causes — Epidemic  cerebro-spinal  meningitis  seems  to  be  much  more 
common  during  cold  weather,  and  is  much  oftener  met  with  during  infancy 
than  at  any  other  period  of  life.  Adults  are  not  exempt  ;  but  the  disease 
prefers  the  young.  It  is  a  disease,  like  typhus,  which  usually  attacks 
the  poor;  and  bad  ventilation  and  insufficient  food  seem  to  prepare  the 
way  for  epidemics.  In  the  city  of  New  York,  the  first  outbreak  of  the 
disease  appeared  in  I860;  and  subsided,  to  reappear,  February,  1872. 


CEREBRO-SPINAL    MENINGITIS.  345 

In  the  sparsely  settled  wards  of  the  city  (the  19th,  20th,  22d),  where 
building  was  going  on  and  fresh  earth  turnfed  up,  it  seemed  to  prevail. 
There  were  45  fatal  cases  during  the  winter  quarter  in  these  wards,  while 
the  entire  number  of  deaths  in  New  York  during  the  same  period  from 
this  cause  was  108.  During  the  spring  quarter  there  were  492  deaths,  148 
being  in  these  wards.  It  subsided  in  the  spring  of  1873,  but  reappeared 
during  the  autumn  of  that  year.  It  would  seem,  from  these  statistics,  that 
overcrowding  had  but  little  to  do  with  the  disease,  but  that  bad  drainage 
(this  portion  of  the  city  being  imperfectly  drained)  had  undoubtedly  some 
influence. 

Morbid  Anatomy — The  meninges  of  the  brain  show  evidences  of 
intense  hyperremia,  the  sinuses  being  distended  with  blood  which  slowly 
coagulates,  and  the  dura  mater  is  the  seat  of  ecchymotic  spots.  There  is 
usually  a  aero-purulent  exudation  beneath  the  arachnoid,  and  this  is  found 
at  the  base  of  the  brain  as  well  as  in  the  ventricles.  It  may  be  recognized, 
also,  in  the  different  fissures  and  sulci.  The  spinal  meninges  are  the  seat 
of  the  same  exudation,  it  being  found  beneath  the  dura,  or  between  the 
arachnoid  and  the  pia  mater.  All  of  the  spinal  membranes  are  vascular,  and 
opaque  in  spots.  The  exudation  appears  to  be  confined  to  the  posterior 
parts  of  the  cord  ;  and  usually,  when  infiltration  in  the  cord  has  taken  place, 
small  elevations  may  be  observed  beneath  the  pia  mater.  According  to 
the  German  pathologists,  the  cervical  portion  of  the  pia  mater  is  not  com- 
monly the  seat  of  exudation.  The  membranes  are  often  adherent,  and 
patches  of  false  membrane  are  visible,  so  that  sometimes  the  sub-cerebral 
nerve-trunks  are  bound  together  and  connected  by  bridges  of  organized 
lymph.  The  nervous  tissue  proper  is  extensively  softened  in  rare  cases, 
especially  if  the  inflammatory  action  has  been  at  all  severe.  Spots  of 
localized  softening  are,  however,  not  uncommonly  observed. 

Diagnosis Cerebro-spinal  meningitis  sometimes  resembles  certain 

irregular  forms  of  malignant  malarial  fever,  on  account  of  intermissions  in 
the  febrile  state.  This  is  the  case  more  especially  during  convalescence, 
when  the  affection  assumes  a  periodical  character.  The  chill  in  cerebro- 
spinal  meningitis  is  not  so  marked  as  in  the  true  malarial  affection,  and 
contractions  of  the  muscles  are  rare  in  any  form  of  malarial  trouble.  The 
other  points  of  difference  may  be  thus  summed  up  : — 

CEREBRO-SPINAL  MENINGITIS.  CONGESTIVE  PERNICIOUS  MALARIA!, 

FEVER. 

Bowels  constipated.  Not  usually  so. 

Pulse  and  temperature  do  not  suffer  Both    subject    to    great    variations, 

rapid  variations.  feeble  and  irregular  (Jones). 

Temperature  does  not  undergo  peri-  Temperature  undergoes  decided  peri- 
odical changes.  odical  changes. 

Face  flushed  ;   eruption.  Complexion  sallow. 

Delirium  and  coma  not  affected  by  All  symptoms   modified   usually  by 

large  doses  of  quinine.  negative  treatment  with  quinine. 

Increase  of  fibrine,  and  rapid  coagu- 
lation of  blood  when  drawn. 


346  CEREBRO-8PINAL    DISEASES. 

A  malignant  typhus,  or  a  masked  variola,  might  counterfeit  cerebro- 
s])inal  meningitis ;  or,  on  the  other  hand,  aero-narcotic  poisoning  might 
simulate  the  affection.  The  absence  of  tetanic  spasms  of  the  post-cervical 
muscles  is,  however,  so  prominent  a  symptom  that  when  it  is  present  the 
probability  of  cerebro-spinal  meningitis  is  considerable. 

Prognosis. — This  disease,  like  other  forms  of  meningitis,  has  a  bad 
character.  Death  is  generally  the  rule,  recovery  the  exception.  In  the 
city  of  Xew  York  the  total  number  of  deaths  from  all  causes  was  29,084 
during  the  twelve  months  ending  Dec.  31,  1873.  Of  these,  9593  were 
placed  under  the  head  of  zymotic  diseases ;  and  the  number  of  deaths  due 
to  cerebro-spinal  meningitis  was  290.  Of  these,  69  were  under  one  year, 
and  104  under  five  years.  Very  few  cases  were  over  thirty.  In  the  ma- 
jority of  cases  the  disease  runs  its  course  in  from  4  to  20  days.  In  fatal 
cases  death  occurs  generally  before  the  12th  day, 

Treatment In  regard  to  treatment,  little  can  be  said  that  will 

be  encouraging.  The  ordinary  antiphlogistic  treatment,  consisting  of 
abstraction  of  blood  by  leeches  applied  to  the  mastoid  processes,  and 
bladders  of  ice  to  the  head,  and  large  doses  of  calomel,  according  to 
some  observers,  have  cut  short  the  disease,  especially  when  these  reme- 
dies were  used  at  its  commencement.  The  almost  wonderful  results 
that  have  followed  the  use  of  ergot  in  large  doses  suggest  this  remedy 
to  us,  and  I  have  no  doubt  that  it  will  prove  to  be  very  efficacious. 
Ziemssen  recommends  morphine,  and  has  never  observed  any  unpleasant 
effects  following  its  employment. 


CEREBRO-SPINAL  SCLEROSIS. 

Synonyms. — ScleVose  en  plaques  dis.«6minees  (Charcot  and  Bourne- 
ville) ;  Insular  sclerosis  (Moxon). 

For  a  long  time  this  disease  was  mistaken  for  paralysis  agitans  (Parkin- 
son's disease),  chorea,  and  other  neuroses  ;  and  even  after  it  had  been 
shown  to  be  a  separate  neurosis  a  certain  amount  of  confusion  existed  in 
regard  to  its  nomenclature  and  its  position  among  the  scleroses.  Charcot 
and  Moxon1  are  to  be  thanked  especially  for  their  successful  efforts  to  give 
it  a  distinct  character. 

Symptoms. — AVe  may  divide  the  progress  of  the  disease  into  three 
stages. 

1st  Stage. — Tin;  first  symptom,  which  is  common  to  several  other  neu- 
roses, is  gradual  loss  of  power  in  the  lower  limbs,  which,  by  itself,  does 
not  attract  attention  to  the  grave  nature  of  the  disease  in  its  incipiency. 
"With  the  weakness  there  is  no  atrophy  and  no  loss  of  sensation,  while 
reflex  excitability  is  either  normal  or  only  slightly  increased.  The  rec- 
tum is  not  affected,  nor  is  the  bladder,  and  there  is  simply  a  paresis  which 
lasts  for  a  variable  time,  perhaps  for  two  or  three  months,  or  for  a  much 

1  Eight  cases  of  insular  sclerosis  of  the  brain  and  spinal  cord,  by  W.  Moxon, 
M.D.,  Guy's  Hospital  Reports,  vol.  xx.,  1875. 


CEREBRO-SPINAL    SCLEROSIS.  347 

longer  period.  The  partially  paralyzed  limbs  become  agitated  by  tremors, 
which  are  seen  best  when  the  patient  takes  some  constrained  position,  or 
attempts  to  walk  a  straight  line.  He  may  have  the  gait  of  an  ataxic,  but 
generally  the  walk  is  more  like  that  of  a  general  paralytic,  being  charac- 
terized by  weakness  of  the  extremities.  As  the  disease  invades  a  higher 
portion  of  the  cord,  we  will  find  tremor  of  the  upper  limbs  and  paralysis 
of  the  cranial  nerves,  indicated  by  symptoms  I  shall  describe  in  speaking 
of  the  descending  variety.  I  may  allude,  however,  to  a  particular  de- 
fect in  articulation,  the  patient  being  unable  to  pronounce  some  of  the 
labial  consonants. 

2d  Stage — Rigidity  of  the  limbs  supervenes,  with  various  contractures 
of  a  spasmodic  character,  and  exaggeration  of  the  tremor.  One  of  my 
patients  died  in  her  bed  with  her  knees  drawn  up  to  her  chin,  her  legs 
flexed  on  the  thighs,  and  her  arms  drawn  closely  to  her  chest.  It  required 
quite  violent  exertion  for  me  to  extend  the  limbs,  and  the  tremor  was 
markedly  aggravated  when  I  did  so.  Electro-muscular  irritability  is  next 
greatly  increased,  and  reflex  excitability  heightened.  Epileptiform  at- 
tacks may  now  appear,  as  well  as  apoplectiform,  and  death  may  occur  at 
this  period  from  the  invasion  of  some  cerebral  vessel  and  consequent  cere- 
bral hemorrhage. 

3d  Stage — This  stage  is  marked  by  rapid  decline  of  the  patient's 
strength.  Incontinence  of  urine  and  feces,  bedsores,  and  dementia  follow, 
and,  after  other  evidences  of  gradual  wasting  away,  death  may  end  the  scene. 

The  course  of  this  form  is :  First,  paresis  of  lower  extremities  and 
tremor ;  second,  contraction,  and  aggravation  of  tremor ;  third,  general 
dissolution. 

1st  Stage  of  Descending  Form :  This  is  the  condition  of  affairs  when 
the  cord  is  attacked  secondarily.  When  the  disease  begins  in  the  brain, 
the  early  symptoms  may  be  headache,  convulsions,  vertigo,  or,  what  is 
more  common,  paralysis  of  some  of  the  cranial  nerves  ;  there  may  be 
ptosis,  strabismus,  loss  of  hearing,  and  facial  paralysis,  or  troubles,  of 
speech  and  embarrassment  in  swallowing.  The  important  symptom  next 
in  advance  is  the  appearance  of  tremor,  which  is  first  seen  in  the  tongue, 
which,  when  protruded,  trembles  visibly  ;  or  it  may  affect  the  lips,  as  may 
be  noticed  when  the  patient  speaks.  The  eyeballs  oscillate  (nystagmus), 
and  the  head  may  become  agitated,  and  afterwards  the  upper  extremities. 
A  peculiarity  characteristic  of  all  forms  of  sclerosis  is  not  absent  here, 
viz.,  the  aggravation  of  tremor  by  voluntary  efforts  made  to  control  it, 
and  its  diminution  during  rest.  If  the  individual  attempts  any  complex 
action,  he  is  utterly  unable  to  complete  it  properly,  for  the  movements 
increase  until  muscular  control  is  entirely  lost.  I  have  alluded  to  the  lost 
sense  of  location,  which  is  also  seen  in  advanced  locomotor  ataxia,  and  I 
may  state  that  it  is  also  a  symptom  of  this  form  of  sclerosis. 

2d  Stage :  The  limbs  lose  their  power  to  a  great  extent  as  the  disease 
advances,  and  permanent  contractures  of  the  upper  and  lower  limbs,  which 
by  this  time  are  affected,  render  the  patient  very  uncomfortable.  His 
forearms  may  be  flexed,  and  the  fingers  are  doubled  up,  as  is  the  case  in 


348  CEREBRO-SP1NAL    DISEASES. 

uncomplicated  lateral  sclerosis.  The  thighs  are  even  flexed  on  the  pelvis, 
and  the  legs  may  be  as  well.  The  knees  are  approximated  quite  forcibly, 
and  it  is  often  difficult  to  separate  them.  This  stage  may  last  for  several 
years. 

3d  Stage :  Meanwhile  the  tremor  has  continued,  and  increased  in  vio- 
lence; but  it  may  sometimes  be  stopped  by  flexing  the  great  toe,  just  as 
Brown-Se"quard  has  shown  may  be  done  in  epilepsy.  The  bladder  and 
rectum  are  now  involved,  and  the  patient  suffers  terribly  from  cystitis. 
and  is  prostrated  by  diarrhoea.  Bedsores  form,  and  he  gradually 
sinks  into  a  state  which  invariably  has  a  fatal  termination.  In  both 
varieties  there  is  great  difficulty  in  articulation,  and  disturbance  of 
function  in  those  organs  supplied  by  the  lower  cranial  nerves.  The  lower 
lip  falls,  and  there  is  dribbling  of  saliva,  while  food  often  remains  in  the 
mouth  wedged  between  the  teeth  and  between  the  gums  and  cheek,  and 
liquids  find  their  way  through  the  nostrils.  Beyond  slight  irritability  and 
restlessness,  there  are  usually  no  mental  symptoms  at  the  outset,  or  until 
the  fixed  stage,  when  sometimes  there  is  intellectual  as  well  as  physical 
decay ;  but  this  is  not  the  rule.  A  case  which  seems  to  be  of  great  interest, 
because  of  the  atrophy  of  the  upper  limbs,  came  under  my  notice  two 
years  ago. 

E.  W.,  aged  37,  salesman,  no  family  history  of  nervous  trouble.  Father 
and  mother  alive;  nothing  to  account  for  his  present  condition.  Five 
years  ago  he  was  employed  in  a  drygoods  store,  and  his  attention  was 
called  to  a  slight  weakness  in  his  thumb  and  forefinger  of  the  right  hand 
when  he  used  his  scissors.  There  was  subsequent  tremor,  which  annoyed 
him  excessively,  and  which  subsequently  became  quite  general.  About  the 
same  time  he  was  subject  to  very  severe  headache,  vertigo,  and  sometimes 
vomiting.  The  tremor  meanwhile  increased,  and  it  became  so  violent  when 
lie  attempted  to  execute  some  fatiguing  act  that  he  was  forced  to  desist. 
He  next  noticed  that  his  vision  was  beginning  to  be  impaired,  that  he  saw 
double,  or  that  "mist  floated  before  his  eyes."  The  trembling  continued, 
and  when  lie  came  to  me  I  found  his  condition  to  be  as  follows:  The  pa- 
tient is  a  tall  man,  of  decidedly  nervous  temperament,  quite  feeble  and 
emaciated,  and  very  much  depressed.  Both  arms  are  convulsed  by  tremors, 
but  especially  the  right.  The  biceps  and  the  extensors  of  the  hand  are  much 
atrophied,  and  there  is  great  loss  of  power,  lie  tells  me  that  the  tremor 
has  been  much  more  violent  than  it  is  now.  The  sensibility  of  the  cuta- 
neous surface  is  rather  lowered,  and  there  is  a  certain  amount  of  analgesia, 
so  that  pins  may  be  run  into  the  dorsal  aspect  of  the  forearm  without  pro- 
ducing pain,  lie  was  able  to  press  the  fluid  in  the  dynamometer  up  to 
7.r»0  with  the  right,  and  to  17  with  the  left.  There  is  still  headache  at 
times,  and  some  dix.xiness.  The  left  eyelid  seems  to  cover  the  eyeball 
more  fully  than  the  right,  and  the  muscles  of  the  left  side  of  the  face  were 
trembling  quite  violently.  When  I  told  him  to  whistle,  his  lips  trembled 
so  much  that  he  could  not  do  so;  and  when  I  requested  him  to  repeat  the 

(•tutterj 

line   "Ben   Battle   was   a   soldier  bold,"  he  did  it   as  follows:   "Me-e-n 

(hdiutlon)  («1ow)  (explosion)    (cxplo«lon)l 

m-m-ni-etta  was  a  s  o  o  g  a  m-mold."     His  articulation  was  quite  defec- 

1  The  intonation  was  very  much  like  what  we  would  expect  to  find  in  "cleft 
palate." 


CEREBRO-SPTNAL    SCLEROSIS.  349 

tive,  and  I  bad  great  difficulty  in  understanding  him.  His  tongue  trem- 
bled, and  his  lower  lip  seemed  to  sag  and  fall  forwards,  and  he  was  obliged 
to  wipe  his  mouth  quite  constantly,  as  there  was  a  considerable  escape  of 
saliva.  When  I  told  him  to  hold  his  head  in  such  a  position  that  I  might 
examine  his  eye  with  the  ophthalmoscope,  it  shook  to  a  great  degree,  and  I 
had  great  difficulty  in  illuminating  the  retina.  He  says  this  is  recent,  and 
that  his  head  was  not  affected  by  tremor  until  a  month  or  two  ago.  His 
mind  is  clear,  and  his  memory  unimpaired.  I  have  seen  him  but  once, 
and  there  has  been  no  advance  in  his  condition. 

The  following  case  is  reported  by  Bourneville: — l 

Rosine  Spitale,  20  years  old.  At  17  years  of  age  she  was  suddenly 
ati'ected  (after  crossing  a  small  stream  and  becoming  chilled)  with  loss  of 
power,  first  in  the  right  lower  extremity,  and  then  in  the  left,  and  some 
time  after  the  hands  began  to  tremble.  At  18  there  was  some  subsequent 
improvement,  but  it  was  very  slight.  Soon  afterwards  menstruation 
ceased,  and  some  time  after  this  the  symptoms  reappeared.  Hemiplegia 
occurred  without  loss  of  consciousness  or  convulsions,  and  the  tongue  and 
eyes  were  involved.  The  disturbances  of  sensation  were  moderate;  there 
was  a  certain  amount  of  numbness  in  the  lower  limbs,  and  a  sense  of  clum- 
siness of  the  tongue,  with  difficulty  in  articulation,  and  some  diminution 
of  mental  power.  At  the  beginning  of  1853  the  patient  was  well  nourished. 
A  half  grain  of  strychnine  daily  has  produced  an  amendment  for  ten  or 
twelve  days.  Electrization  produced  movements  in  the  lower  limbs,  and 
increased  the  trembling  in  the  Upper  extremities.  In  the  course  of  the 
month  the  paresis  of  the  inferior  extremities  was  nearly  complete,  the 
trembling  of  the  eyes  with  dilatation  of  the  pupils  is  quite  pronounced, 
and  the  patient  has  become  very  stupid. 

January,  1854.  The  hands  tremble  less  than  they  did.  There  are  in- 
voluntary discharges  of  urine.  Ergot  JU  Per  day  has  been  used  for 
several  months.  It  acted  once  upon  the  sphincters,  and  seemed  to  improve 
the  weakness  of  the  limbs,  for  several  movements  were  possible. 

Spring,  1854.  Bedsore  on  sacrum. 

September.  In  a  state  of  decline;  the  bedsore  has  extended  very  rap- 
idly; pain  in  the  head;  pulse  136. 

October.  Repeated  rigors ;  sensibility  of  the  inferior  limbs  returned ; 
feebleness  of  the  extensors  of  the  back;  scoliosis  towards  the  right;  the 
trembling  in  the  extremities  persists. 

Noiiember  1.  Death,  preceded  by  involvement  of  the  muscles  of  the 
pharynx. 

Autopsy — The  gray  matter  is  hard;  the  nervous  substance  in  the 
neighborhood  of  the  lateral  ventricles  and  that  of  the  protuberance  were 
hard.  We  found  gray  nodules  superficial  and  deep.  The  white  substance 
had  become  hard  in  spots.  Beneath  the  microscope  the  indurated  nodules 
(white)  consisted  of  a  fibrous,  mass-like,  connective  tissue;  the  elements 
of  the  nervous  matter  had  almost  entirely  disappeared;  and  the  white 
nodules  were  pressed  beneath  the  surface  of  the  cut.  The  spinal  cord 
was  indurated.  The  great  vessels  and  viscera  were  healthy. 

Dr.  Geo.  S.  Gerhard2  has  presented  the  following  interesting  case  of  this 
disease  : — 

1  La  Scl6rost>,  etc.,  Paris,  1869,  p.  92. 

2  Philadelphia  Medical  Times,  November  11,  1876. 


350  CEREBBO-SPINAL    DISEASES. 

Samuel  A.,  ret.  57,  a  native  of  Ireland,  and  a  blacksmith  by 
was  admitted  into  the  out-patient  department  of  the  Infirmary  for  Nervous 
Diseases  on  September  17,  1870,  and  gave  the  following  history.  His 
health  had  always  been  good  until  about  seven  years  ago,  when,  after  no 
known  cause,  he  began  to  lose  power  in  the  legs.  One  year  after  this  his 
arms  grew  weak,  and  he  then  observed  for  the  first  time  that  any  move- 
ment of  the  upper  or  lower  extremities  was  accompanied  by  tremor.  At  a 
somewhat  later  period  his  speech  became  affected.  The  weakness  of  his 
limbs  and  the  trembling  gradually  increased,  until  finally,  about  four  years 
ago,  he  was  obliged  to  give  up  work. 

On  admission  there  is  decided  loss  of  power  in  the  upper  and  lower 
extremities,  and  upon  his  attempting  to  use  either,  a  large  and  jerky  tremor 
is  developed.  He  walks  with  the  assistance  of  a  cane,  but  his  movements 
are  slow,  and  his  feet  clear  the  ground  with  much  difficulty.  His  grip, 
particularly  that  of  the  right  hand,  is  feeble,  squeezing  the  dynamometer 
with  the  former  to  100°  and  with  the  latter  to  1 10°.  In  the  upper  extremi- 
ties the  trembling  is  especially  well  shown  during  the  performance  of  an 
act  requiring  some  little  time  for  its  execution,  such  as  lifting  a  glass  of 
water  to  the  mouth.  The  tremor  also  involves  the  muscles  of  the  head 
and  trunk,  but  it  ceases  entirely  when  the  patient  is  in  a  state  of  absolute 
repose.  There  is  no  muscular  wasting,  no  loss  of  electrical  response,  and 
no  disturbance  of  sensibility. 

His  mental  faculties  are  decidedly  impaired,  and  his  speech  is  thick 
and  deliberate,  there  being  a  decided  interval  between  each  word.  His 
eyesight  is  poor,  and  examination  of  the  fundus  reveals  commencing 
atrophic  changes,  as  shown  by  attenuation  of  the  vessels  and  a  genenil 
pallor  of  the  optic  disk  ;  there  is  also  slight  nystagmus.  The  unsteadiness 
of  gait  and  the  tremor  are  not  increased  by  closure  of  the  eyes.  His  urine 
is  in  all  respects  normal,  and  he  has  no  loss  of  control  over  the  bladder  or 
bowels. 

Causes. — Jaccoud  is  of  the  opinion  that  sclerosis  occurs  as  a  disease 
of  childhood  or  adult  life  up  to  45  years,  and  that  there  is  nothing  to  indi- 
cate the  special  liability  of  either  sex;  while  Charcot  considers  it  a  dis- 
ease which  is  much  more  common  among  females  than  males,  and  that  it 
rarely  appears  after  40.  Of  six  cases  I  have  recorded  their  respective  ages 
were  18,  26,  33,  37,  41,  40;  four  were  males  and  two  females.  Of 
eighteen  cases  collected  by  Bourneville  fifteen  were  women  and  three  men. 
In  three  of  these  the  disease  began  between  30  and  40,  three  between  30 
and  35,  and  the  others  between  15  and  30.  Of  Hammond's  cases,  eleven 
were  men  and  two  women.  Very  little  is  known  in  regard  to  the  etiology 
of  sclerosis;  but  "  moist  cold,"  emotional  excitement,  and  venereal  excesses 
are  spoken  of  by  the  different  Continental  writers  as  causes. 

Bourneville  found  that  the  greater  number  of  his  cases  died  between  35 
and  .»(>,  and  that  the  disease  appeared  in  most  instances  between  the  ages 
of  20  and  35.  In  one  of  my  patients  the  disease  began  at  the  oth  year, 
in  another  at  about  the  18th  year,  and  in  the  third  and  fourth  at  32,  and 
in  the  fifth  and  sixth  between  35  and  40. 

Morbid  Anatomy  and  Pathology — I  have  spoken  in  another 
chapter  about  the  morbid  appearances  in  sclerosis,  and  nothing  remains  to 


ALCOHOLISM.  351 

be  said  in  regard  to  this  particular  form.  It  is  only  a  question  of  location 
that  concerns  us,  and  after  death  we  will  probably  find  patches  of  tissue 
scattered  through  the  brain  and  cord.  The  antero-lateral  columns  seem 
to  be  invaded  in  nearly  all  cases,  and  this  would  appear  probable  from  the 
contractures. 

Diagnosis — In  the  ascending  form  it  must  be  remembered  that  the 
tremor  follows  the  paresis,  while  the  descending  form  is  characterized  by 
tremor  as  a  primary  affection,  or  at  least  before  the  muscular  paresis  of  the 
extremities.  Paralysis  agitans  may  be  confounded  with  the  descending 
form  of  the  advanced  disease  ;  the  tremor  in  the  former  disease  is  continu- 
ous, and  is  often  not  affected  by  quieting  influence  or  sleep,  but  is  not 
aggravated  by  efforts  of  the  will.  The  early  symptoms  of  this  form  may 
also  point  to  progressive  paralysis  of  the  insane,  and  to  intracranial  tumors  ; 
but  the  subsequent  progress  of  the  affection,  the  development  of  new  symp- 
toms, and  the  common  absence  of  neuro-retinitis,  are  sufficient  to  remove 
any  doubts  as  to  its  true  nature. 

Prognosis — Invariably  bad. 

Treatment — I  know  of  no  remedy  that  can  reconstruct  a  degenera- 
tion of  nerve-tissue  which  consists  in  proliferation  of  connective-tissue 
cells,  and  nerve-tube  disappearance.  Nitrate  of  silver,  chloride  of  gold, 
galvanism,  bichloride  of  mercury,  and  chloride  of  barium  have  been  all 
used.  It  seems  that  only  one  chance  may  exist — the  possibility  of  syphilis. 
If  this  be  present,  it  is  probable  that  specific  treatment  will  be  successful. 
We  are  to  improve  the  patient's  general  condition,  and  relieve  his  tremor 
either  by  conium  or  hyoscyamus,  and  make  him  as  comfortable  as  possible. 

ALCOHOLISM. 

ACUTE CHRONIC. 

Synonyms Ebrietas,  Alcoholismus,  Delirium  tremens;  Mania  a 

potu,  Alcoolisme ;  Trunksacht ;  Chronic  alcoholic  intoxication  (Reynolds). 

Definition. — A  disease  of  the  nervous  system  resulting  either  through 
direct  action  of  alcohol  upon  its  tissues,  or  through  impairment  of  other 
organs  which  fail  to  remove  effete  substances  from  the  blood  ;  and  symp- 
tomatized  by  mental  aberration,  and  by  various  sensorial  and  motorial 
phenomena,  usually  the  result  of  lowered  functional  activity. 

The  immoderate  use  of  alcoholic  beverages  is  usually  followed  by  the 
most  deplorable  consequences.  Sad  to  say,  this  condition  is  too  familiar 
to  need  any  extended  description,  as  far  as  the  appearance  of  the 
patient  is  concerned ;  but  there  are  other  features  of  the  disease  that  need 
earnest  and  careful  study. 

The  effects  of  alcohol  upon  the  human  being  may  be  said  to  be  physiolo- 
gical and  pathological.  The  sensorial  alterations  are  much  more  interest- 
ing than  the  motorial,  and  of  these  we  will  speak  in  detail. 

The  imbibition  of  a  moderate  amount  of  alcohol,  as  we  know,  is  usually 


352  CEREBRO- SPINAL    DISEASES. 

followed  by  a  general  feeling  of  comfort,  a  certain  degree  of  exhilaration. 
The  individual  is  no  longer  absorbed  in  himself.  He  is  animated  and  gay, 
his  ideas  flow  rapidly,  and  he  becomes  filled  with  greater  energy  and  t-n- 
duranoe.  If  the  dose  be  increased,  the  mental  functions  become  more 
active.  He  is  excited  and  demonstrative,  and  either  violent  and  noisy,  or 
tender  and  maudlin,  according  to  the  thoughts  which  have  most  engrossed 
his  attention,  or  through  the  influence  of  temperament.  Incoherence  of 
speech  and  confusion  of  ideas  succeed  the  ordinary  mental  excitement, 
and  this  may  be  followed  by  a  condition  of  stupor,  the  individual  IK  •coin- 
ing perfectly  unconscious  of  injury,  and  unmindful  of  either  bruises  or 
cuts,  or  even  severe  burns.  He  may  stagger  and  fall,  and  lie  in  some  ex- 
posed place  regardless  of  the  blaze  of  the  sun,  the  flies,  and  the  noise.  He 
has  finally  become  reduced  to  what  Magnan1  calls  "  la  vie  ve'ge'tative."  He 
is  "  dead  drunk."  This  deep  alcoholic  stupor  may  last  for  some  time,  and 
end  the  patient's  career ;  or  he  may  become  maniacal  instead,  or  present 
the  condition  described  by  Percy*  under  the  name  d'ivres&e  convulsive, 
in  which,  with  clonic  convulsions,  he  grows  furiously  maniacal,  grinding 
his  teeth,  and  cursing  and  menacing  those  about  him.  The  maniacal 
attacks  are  no  doubt  influenced  to  some  degree  by  the  character  of  the 
illusions  and  hallucinations. 

ACUTE  ALCOHOLISM. 

Symptoms — The  continued  use  of  alcohol  in  excess  for  a  week  or 
two,  such  as  occurs  during  an  ordinary  debauch,  is  very  apt  to  lead  to  an 
attack  of  delirium  tremens.  This  state  of  acute  alcoholism  may  also  occur 
should  the  patient,  who  has  drunk  not  necessarily  to  intoxication,  but  to 
a  degree  almost  approaching  it,  be  deprived  of  his  drink. 

One  of  the  earliest  indications  of  this  state  of  alcoholism  is  a  tremu- 
lousness  or  "  shakiness,"  which  is  quite  marked  in  the  early  part  of  the 
day,  and  is  connected  with  nausea  and  want  of  appetite.  The  patient  is 
restless  and  irritable,  sleeps  poorly,  and  presents  an  appearance  of  dejec- 
tion and  sadness.  His  eyes  are  red  and  watery,  and  his  skin  is  of  a 
muddy  color.  His  features  are  drawn  and  haggard,  and  he  is  a  wretched 
object  indeed.  The  gastric  irritability  may  be  so  great  as  to  prevent  any 
retention  of  food,  and  the  simplest  forms  of  nourishment  are  ejected  by 
the  stomach.  Constipation  is  obstinate,  and  the  urine  is  passed  in  small 
quantities  and  loaded  with  the  urates,  so  that  a  dense  brick-dust  precipi- 
tate is  found  in  the  chamber.  The  attack  is  immediately  preceded  by 
great  excitability,  and  by  illusions  and  hallucinations,  which  grow  very 
marked  as  the  patient  becomes  noisy  and  violent.  Magnan  has  graphi- 
cally described  the  different  varieties  of  mental  trouble.  The  patient  may 
be  sad  and  utterly  dejected.  He  may  imagine  that  he  has  committed 

1  R^cherohes  sur  les  centres  nerveux,  p.  11G. 

1  Ivrosse  Convulsive,  Dictionnaire  dcs  Sciences  Mgdicales,  t.  xxvi.,  p.  249. 


ALCOHOLISM.  353 

some  great  crime ;  that  he  has  been  sentenced  to  death  ;  that  he  is  being 
executed ;  and  these  delusions  may  markedly  influence  the  character  of 
his  outward  expression.  In  nearly  every  case  there  is  some  delusion  of 
persecution  of  a  horrible  kind.  The  attack  usually  begins  with  hallucina- 
tions of  a  visual  character,  in  which  snakes  and  other  reptiles,  devils, 
imps,  gnomes,  and  goblins  terrify  the  patient.  In  one  instance  which  I 
remember,  he  was  tortured  by  devils  who  held  lighted  candles,  and 
were  about  to  set  his  clothes  on  fire ;  in  another  case  the  patient  en- 
deavored to  escape  a  falling  weight.  The  illusions  are  always  followed  by 
hallucinations,  and  finally  by  delusions.  The  irritations  of  the  organs  of 
sense  are  distorted  so  that  the  simplest  and  most  common  noises  become 
changed  by  the  patient's  disordered  imagination  into  the  most  terrible 
sounds.  The  cry  of  the  vendor  in  the  street  is  likened  to  the  despairing 
shriek  of  a  lost  soul.  The  stroke  of  the  clock,  a  funeral  bell,  and  the 
voices  of  those  in  the  room  are  supposed  to  be  the  savage  yells  of  a  howl- 
ing mob.  The  objects  which  the  patient  sees  are  nearly  always  trans- 
formed into  animals,  which,  controlled  by  no  natural  laws,  run  over  the 
ceiling,  or  gallop  through  the  air.  Odors  are  reversed,  and  food  is  sup- 
posed to  be  poisoned.  Animals  run  over  the  skin  ;  sometimes  they  are 
rats  or  lizards  ;  and  at  others  he  may  call  attention  to  the  torture  inflicted 
by  thousands  of  needles  or  cutting  instruments.  Maniacal  outbursts  are  the 
common  feature  of  the  attack,  the  patient  seeming  to  possess  herculean 
strength,  and  it  is  sometimes  necessary  to  have  six  or  eight  strong  men  to 
prevent  him  from  throwing  himself  out  of  the  window,  or  committing 
some  deed  of  violence.  He  may  remain  in  this  condition  for  seveial 
days  at  a  time,  during  which  period  he  neither  sleeps  nor  eats.  His 
eyes  are  bloodshot,  and  he  sweats  profusely.  The  pulse1  is  very  rapid, 
small,  and  irritable,  and  though  the  deep  temperature  may  reach  102°  or 
103°  F.,  the  hands  and  feet  are  cold,  and  the  palms  and  soles  clammy. 

When  recovery  takes  place,  the  first  change  for  the  better  is  sleep. 
The  violent  symptoms  subside  gradually  in  the  reverse  order  of  their 
appearance.  He  may  awake,  after  fifteen  or  eighteen  hours,  irritable, 
but  not  much  better  ;  or  there  may  be  a  lesser  degree  of  excitement, 
more  sleep,  and  gradual  improvement. 

In  other  cases  death  follows,  there  being  a  subsidence  of  the  violent 
delirium,  which  changes  its  character  and  becomes  muttering;  when  he 
relapses  into  a  typhoid  state,  and  gradually  passes  away. 

The  tendency  to  the  commission  of  deeds  of  violence  is  quite  charac- 
teristic of  acute  alcoholism.  Of  377  cases  observed  by  Bouchereau  and 
Magnan*  in  the  year  1870,  twenty-four  attempted  to  commit  suicide,  and 
nine  attempts  at  homicide  were  made.  These  cases  were  seen  under 

1  The  sphygmograph  has  been  employed  by  Anstie  in  cases  of  delirium  tre- 
mens,  and  the  tracing  obtained  very  closely  resembles  that  of  the  typhoid  fevers 
and  inflammation.     It  is  of  a  marked  dierotic  type. 

2  Op.  cit.,  p.  129. 

23 


351  CEREBBO-8PINAL    DISEASES. 

restraint,  but  among  the  cases  which  occur  outside  of  hospitals  and  asy- 
lums, the  number  is  far  greater. 

CHRONIC  ALCOHOLISM. 

Symptoms A  much  more  grave  condition  of  affairs  follows  the 

continued  use  of  large  quantities  of  alcohol,  and  no  more  hopeless  disease 
exists  than  that  of  which  we  are  about  to  speak.  While  in  delirium  tre- 
mens  recovery  may  take  place,  followed  by  total  reformation,  without 
any  serious  damage  to  the  nervous  system,  the  more  serious  nerve-changes 
wrought  by  constant  saturation  can  never  be  repaired,  but  tend  to  further 
degeneration  and  decay. 

Chronic  alcoholism  begins  by  a  number  of  insidious  alterations  in  the 
nervous  substance,  whereby  its  functional  activity  is  embarrassed,  and  minor 
symptoms  at  first,  and  more  grave  ones  afterwards,  appear  very  gradually 
and  progressively. 

The  victim  of  chronic  alcoholism  may  present  the  symptoms  of  tremor 
and  loss  of  power  of  which  I  have  before  spoken.  The  tremor  is  rhyth- 
mical, and  begins  at  first  in  the  extremities,  and  afterwards  involves  the 
entire  body.  There  seems  to  be  an  accompanying  want  of  power,  for  he 
relaxes  his  hold  upon  any  object  he  may  grasp  when  his  attention  is 
diverted.  His  morning  dram  involves  an  effort  worthy  of  a  better  cause. 
He  grasps  the  glass  with  both  hands,  fearing  that  he  may  spill  even  a  single 
drop  of  the  precious  liquid,  and  carries  it  carefully  to  his  mouth,  clutching 
the  rim  of  the  glass  between  his  teeth,  oftentimes  with  sufficient  force  to 
bite  out  a  piece.  The  lower  extremities  become  involved,  and  the  patient 
shuttles  along  in  a  clumsy  manner,  his  feet  being  scarcely  lifted  from  the 
ground.  His  dress  becomes  disorderly,  and  his  habits  are  no  longer  char- 
acterized by  neatness  and  tidiness.  His  facial  muscles  lose  their  play,  and 
his  countenance  wears  a  wonderfully  woebegone  and  sorrowful  expression. 
He  wanders  wretchedly  from  one  grog-shop  to  another ;  eats  sparingly, 
and  rarely  ever,  unless  his  worn-out  stomach  is  stimulated  by  a  dram.  He 
loses  flesh,  and  his  clothes  hang  to  his  withered  limbs  like  the  vestment  of 
a  scarecrow.  This  is  but  the  first  step  in  the  advancing  disease.  Memory 
becomes  weakened,  and  forgetting  even  faces  and  names,  he  drops  one  by 
one  his  old  friends,  and  sits  in  loneliness  for  hours  at  a  time. 

The  mind  is  utterly  sapped,  and  lie  is  reduced  to  a  state  of  dementia. 
Numerous  grave  changes  occur  in  addition  to  these.  Speech  becomes  thick 
and  unintelligible.  In  the  early  stages  there  may  be  convulsions  or  attacks 
of  delirium  tremens  ;  but  one  of  the  most  striking  and  serious  expressions  of 
the  disease  is  the  occurrence  of  paralysis ;  and  there  may  be  hemiplegia  or 
paralysis  of  a  local  character,  the  third  nerve  becoming  implicated  and 
ptosis  resulting.  The  subject  of  chronic  alcoholism  is  generally  anaesthetic, 
and  this  to  a  marked  degree.  Not  only  is  tactile  sensibility  impaired,  so 
that  he  is  unable  to  determine  the  nature  of  even  a  rough  object,  but  he  is 
unaffected  by  extremes  of  temperature.  In  one  case  which  I  can  recall,  this 
was  illustrated  by  the  fact  that  in  sitting  before  the  fire  he  thrust  his  foot 


ALCOHOLISM.  355 

beneath  the  grate,  and  left  it  there  for  some  time  before  his  position  was 
discovered  by  a  member  of  the  family.  Hemi-anaesthesia1  is  spoken  of  by 
some  writers,  but  it  is  an  extremely  rare  feature  of  the  disease,  and  is  pro- 
bably a  late  symptom  resulting  from  organic  changes  on  one  side  of  the 
brain.  Hammond2  alludes  to  the  anaesthetic  condition  of  the  cornea,  which 
is  occasionally  not  affected  in  the  least  by  the  touch  of  the  finger. 

Convulsive  seizures  of  different  kinds  are  occasional  evidences  of  the 
serious  effects  of  alcohol.  These  may  vary  from  simple  spasm  to  a  variety 
of  convulsion  which  closely  resembles  a  marked  epileptic  paroxysm.  In 
fact  the  diagnosis  is  oftentimes  very  difficult.  What  I  have  said  about  the 
mental  condition  in  acute  alcoholism  may  be  now  applied.  The  halluci- 
nations and  lighter  forms  of  sensory  and  mental  aberration  exist  at  different 
stages,  but  towards  the  end  the  condition  is  one  of  dementia  of  the  most  pro- 
found character,  the  patient  being  completely  oblivious  of  the  outside  world, 
and  of  his  duties  to  society.  He  is  morally  irresponsible,  and  the  crimes 
he  may  commit  are  motiveless  and  dictated  only  by  a  diseased  mind. 

Causes. — Chronic  alcoholism  follows  the  steady  use  of  large  quantities 
of  alcoholic  liquors,  but  is  rarely  found  among  those  who  drink  wine  or 
malt  liquor.  The  French,  Italians,  or  Germans  are,  therefore,  seldom 
affected  in  their  own  countries,  especially  outside  of  the  large  cities,  where 
a  very  small  amount  of  ardent  spirits  is  taken.  In  England,  Scotland, 
Ireland,  and  America  the  case  is  different,  for  in  these  countries  there  is 
no  low -priced  light  beverage  which  takes  the  place  of  the  wines  and  beer 
of  the  European  Continent,  Avhich  are  drunk  in  preference  to  water. 
Without  entering  into  the  discussion  of  the  effects  of  alcohol  upon  other 
organs  of  the  body  than  those  of  the  nervous  system,  it  may  be  said  that 
the  condition  known  as  alcoholism  springs  from  a  protracted  use  of  large 
quantities  of  strong  liquor,  so  that  the  nervous  substance  is  deprived  of  its 
normal  nutrition,  the  blood  being  charged  with  effete  substances  which 
should  be  eliminated  by  the  kidneys,  lungs,  and  skin. 

Delirium  tremens  is  due  generally  to  the  direct  action  of  a  large  quan- 
tity of  alcohol,  which  produces  overwhelming  toxic  effects  ;  while  chronic 
alcoholism  implies  a  structural  degeneration  due  to  the  continued  action  of 
the  alcohol  itself,  and  to  the  vitiated  blood. 

Delirium  tremens  may  occur  either  from  a  sudden  cessation  of  indul- 
gence, or  in  the  midst  of  a  prolonged  debauch,  most  commonly,  however, 
the  latter.  In  some  persons  elimination  goes  on  so  perfectly  that  large 
quantities  of  liquor  may  be  taken  and  disposed  of  without  any  pro- 
found effect  upon  the  nervous  system  being  produced.  These  individuals 
may  drink  to  a  point  much  beyond  moderation,  and  still  suffer  no  marked 
inconvenience,  the  alcohol  seemingly  affecting  some  other  organ,  which 
may  be  either  the  liver  or  kidneys,  so  that  cirrhosis  or  degeneration  of 
other  kinds  may  take  the  place  of  the  cerebral  trouble  in  the  beginning. 

1  Magnan  considers  that  hemi-ansesthesia  and  general  paralysis  are  quite  com- 
mon results  of  chronic  alcoholism,  op.  cit.,  p.  134. 

2  Diseases  of  the  Nervous  System,  p.  850. 


Acute  alcoholism  (D.  T.)      ]  j87i  42 


356  CEREBRO-SPINAL    DISEASES. 

Males  are  much  more  often  affected  than  females,  as  the  statistics  of 

Magnan  show  :— 

M.         F. 

1870     .     .     35  2 

2 

f  1870     .     .  216         51 
Subacute  -j  jg7j  j^g         47 

f 1870     .     .  126         11 
11871     .     .     90         14 

•  This  fact  has  been  confirmed  by  statistics  collected  by  the  Health  De- 
partment of  New  York.  During  the  year  1873,  45  deaths  were  reported 
from  delirium  tremens,  but  four  of  whom  were  females.  It  is  probable  that 
there  were  many  more  cases  which  were  not  reported  as  such. 

Women,  however,  though  not  so  subject  to  chronic  alcoholism  as  men, 
often  drink  to  excess,  and  not  rarely  develop  delirium  tremens.  This 
bad  habit  is  confined  chiefly  to  either  extreme  of  society — the  very  lowest 
class,  or  the  highest  in  the  social  scale.  Among  the  latter  the  amount  of 
private  dram-drinking  is  astonishing ;  and  though  the  "  skeleton  in  the 
closet"  is  carefully  guarded  by  the  friends  of  the  patient,  it  is  by  no  means 
uncommon  for  the  physician  to  be  called  in  to  attend  cases  of  delirium 
tremens  in  high  life. 

Absinthe,  which  is  extensively  used  in  Paris,  and  is  beginning  to  be 
introduced  into  this  country,  produces  a  terrible  form  of  delirium  tremens, 
in  which  mania  is  a  marked  feature ;  and  a  form  of  epileptiform  attack  is 
also  quite  common. 

Alcoholism  is  much  more  often  observed  between  the  twentieth  and  the 
fiftieth  year,  and  is  very  rare  before  that  time. 

As  to  hereditary  predisposition  there  is  a  great  deal  to  be  said,  but  when 
we  attempt  its  consideration  we  depart  from  the  immediate  subject.  Oc- 
cupation and  mental  influences  have  much  to  do  with  the  making  of  drunk- 
ards or  hard  drinkers.  Barkeepers,  and  individuals  exposed  to  severe 
weather,  are  commonly  addicted  to  drink  ;  the  one  either  feeling  obliged 
to  be  convivial  or  indulging  only  because  the  liquor  is  so  accessible,  and  the 
other  because  he  "  needs  something  to  keep  out  the  cold."  Mental  depres- 
sion, grief,  and  business  worry  are  interesting  in  their  social  features,  but 
do  not  strictly  come  within  the  scope  of  an  article  of  this  character. 

Morbid  Anatomy  and  Pathology — The  prolonged  use  of 
alcohol  is  followed  by  marked  changes  in  the  structure  of  the  nervous 
substance.  In  the  early  stages  there  may  be  found  appearances  which 
are  ordinarily  met  with  in  uncomplicated  cerebral  congestion,  viz.,  enlarged 
vessels,  injected  meninges,  and  effusions  of  serum.  These  may  vary  greatly 
in  their  extent  and  appearance,  and  may  be  associated  with  a  fatty  degene- 
ration of  the  vascular  walls,  patches  of  softening,  or  even  little  foci  of  in- 
duration. The  disease  leaves  its  traces  most  indelibly  stamped  as  menin- 
geal  thickening  and  opalescence,  and  perhaps  encysted  collections  of  blood, 
which  have  been  described  in  speaking  of  pachymeningitis.  The  sinuses 
are  engorged,  and  the  dura  mater  may  be  adherent  to  its  underlying  mem- 


ALCOHOLISM.  t  357 

branes  ;  or  they,  in  turn,  may  be  in  such  close  contact  in  spots  with  the 
cortex  that  their  removal  necessitates  the  tearing  out  of  patches  of  super- 
ficial gray  substance.  The  convolutions  will  be  found  to  be  atrophied  and 
reduced  in  size,  and  the  ganglia  at  the  base  are  often  greatly  softened. 

Many  observers,  among  them  Carlisle  and  Percy,  have  found  alcohol  in 
the  fluids  in  the  ventricles.  Besides  these  intracranial  changes,  the  liver, 
kidneys,  and  stomach  present  appearances  with  which  all  pathologists  are 
familiar.  The  arteries  throughout  the  body  are  found  to  have  undergone 
atheromatous  degeneration,  and  this  is  seen  in  the  brain  to  a  very  decided 
degree.  As  to  the  condition  alluded  to  by  various  observers,  viz.,  the* 
mechanical  change  exerted  directly  by  the  contact  of  alcohol  with  the  tis- 
sues, I  think  there  has  been  much  exaggeration.  The  sclerosis  so  often 
seen  is  much  more  probably  the  result  of  interstitial  inflammatory  change 
than  a  chemical  transformation. 

The  experiments  made  by  Anstie,1  Magnan,2  Percy,  Marce*t,3  and 
Motet4  settle  with  great  certainty  the  pathological  processes  which  follow 
the  toxic  administration  of  alcohol.  Anstie  took  a  full-grown  dog  weigh- 
ing 10  Ib.  4  ozs.,  and  injected  6  ozs.  of  mixed  alcohol  and  water  into  the 
stomach  at  1  P.  M.  No  food  had  been  taken  for  four  hours  previously. 

1.4P.M.  Animal  obviously  affected;  staggers  in  walking,  and  fre- 
quently falls  down.  The  hind  quarters  are  weak,  and  skin  of  hind  limbs 
insensitive.  Resp.  24;  circulation,  140. 

1.6  P.  M.  Dog  lies  extended  on  the  floor  quite  drowsy,  but  capable  of 
being  roused  ;  fore-limbs  retain  slight  degree  of  voluntary  power.  Tongue 
protruded,  and  the  dog  "  slavers"  still.  Skin  about  mouth  anaesthetic  ; 
conjunctiva  sensitive. 

1.7.30  P.  M.  Animal  falls  on  its  side,  comatose  and  snoring.  Conjunc- 
tiva insensitive  with  other  parts.  Resp.  20;  circulation,  184,  tolerably 
strong.  Ano-genital  region  was  sensitive  to  painful  impressions.  Pupil 
strongly  contracted  at  first,  but  became  dilated  at  1.25,  little  sensitive  to 
light ;  anaesthesia  remained  ;  eyes  still  insensitive  ;  continuous  tremor  of 
hind-legs  began  and  continued  for  a  short  time.  Respiration  declined  in 
frequency  and  became  gasping,  and  ceased  at  3.5  P.  M.,  two  hours  after 
the  ingestion  of  the  alcohol,  the  heart  beating  64  per  minute.  It  remained 
irritable  for  some  minutes  later.  Much  more  complete  and  earlier  coma 
followed  the  administration  of  larger  doses. 

The  continued  toxic  use  of  alcohol  produces  changes  not  only  upon  the 
nervous  system  directly,  but  secondarily  through  other  organs  which  are 
primarily  affected.  A  large  quantity  of  alcohol  taken  into  the  system  in- 
duces pathological  changes  somewhat  after  the  following  manner  :  A  cer- 
tain portion,  quite  small  in  amount,  is  excreted,  and  may  be  detected  in 
the  breath,  urine,  bile,  and  sweat,  while  the  greater  proportion  remains  in 

1   Stimulants  and  Narcotics,  p.  335  et  seq.  3  Op.  cit.,  p.  117. 

3  DC  la  folie  causee  par  1'abus  des  boissons  alcooliques,  these  de  1847. 

4  Considerations  generates  sur  1'alcoolisme,  et  plus  particulierement  des  effets 
toxiques  sur  1'homme  par  la  liqueur  d' absinthe,  1859. 


358 


CEREBBO-8PINAL    DISEASES. 


the  blood,  greatly  altering  its  character  and  inducing  a  large  number  of 
interesting  changes.  Lallemand,  Marcel,  and  various  experimenters  have 
found  that  the  excretions  contained  much  pure  alcohol,  and  others  have 
detected,  by  the  chromic  acid  test,  traces  of  alcohol  forty-eight  hours  after- 
wards. Anstie  declares,  however,  that  but  the  merest  fraction  of  the 
amount  taken  is  eliminated  in  its  unchanged  form.  In  this  conclusion  lie 
differs  from  the  authorities  I  have  quoted.  The  alcohol  remaining  in  the 
blood  is  partially  eliminated  in  its  decomposed  state  (carbonic  oxide  ami 
water),  while  a  certain  quantity  remains.  The  internal  organs  are  con- 
gested, notably  the  liver,  kidneys,  and  lungs,  so  that  excretion  is  very 
slowly  performed,  and  the  urine  voided  is  scanty  in  amount,  devoid  of 
the  chlorides,  and  rich  in  urates.  The  blood  circulates  sluggishly,  and 
contains  fat  and  sugar.  I  have  also  found  sugar  in  the  urine,  which  pro- 
bably resulted  from  irritation  of  the  medulla  as  well  as  certain  disturbances 
of  kidney  and  liver  function. 

The  abundance  of  carbonic  acid  requires  double  duty  upon  the  part  of 
the  lungs,  and  consequently  respiration  becomes  labored  and  quickened. 
The  natural  oxidation  of  the  blood  is  seriously  embarrassed,  and  elimina- 
tion is  retarded  most  seriously. 

The  nervous  system  of  course  suffers  from  this  change  in  its  badly  nour- 
ished state.  Degeneration  of  the  nervous  elements  follows,  and  interstitial 
thickening  and  medullary  metamorphoses  take  place,  so  that  the  loss  of 
function  is  very  great.  The  pneumogastric  being  implicated,  the  lungs 
and  other  organs  are  not  properly  innervated,  and  many  of  the  curious 
evidences  of  such  disorder  follow.  This  is  illustrated  by  the  tendency  to 
pneumonia  which  often  exists  as  a  feature  of  alcoholism. 

The  sympathetic  system  is  of  course  implicated.  The  actual  presence 
of  alcohol  is  attended  by  vaso-motor  paresis,  and  a  number  of  vascular 
changes  probably  follow.  It  might  be  well,  before  closing,  to  refer  to  a 
condition  of  the  cranial  bones  noted  by  Lancereaux  and  others.  A  hard- 
ening and  thickening  is  due  to  nutritive  changes,  which  Anstie  thinks  is 
not  a  true  hypertrophy,  as  the  original  texture  of  the  bone  is  lost. 

Prognosis — A  table  prepared  by  Mr.  Neilson  from  the  Registrar- 
General's  report  shows  that  the  probable  duration  of  life  in  individuals 
who  have  reached  the  20th,  30th,  40th,  50th,  and  60th  years,  and  who 
have  been  either  temperate  or  intemperate,  is  about  the  following : — 


Having  reached 
the  age  of 

Has  an  average  chance 
of  still  surviving 

But  the  intemperate  have  an  average  chance 
of  surviving  only 

20 
30 

44.21  years 
36.48     " 

15.53  years,  or  35  per  ct.  of  the  duration  of 
life  of  the  general  population. 
13.80     "      "    38          '           "           " 

40 

28.79     " 

11.62     "      "    40          '           "           " 

50 

21.  25      " 

10.86     "     "51          '           "           " 

GO 

14.28     " 

8.94     "      "    63          '           "           " 

This  applies  only  in  a  general  way  to  the  subject,  but  is  significant  in 
showing  how  greatly  the  alcoholic  habit  diminishes  the  patient's  chances. 


ALCOHOLISM.  359 

In  regard  to  the  prognosis  of  the  actual  attack,  there  is  rarely  any  rea- 
son to  fear  a  fatal  termination  unless  the  patient  has  had  a  number  of 
previous  ones.  Coma  and  convulsions  should  be  looked  upon  with  grave 
suspicion,  as  they  greatly  diminish  the  patient's  tendency  to  recovery. 
Chronic  alcoholism  is  more  unfavorable.  Should  the  patient  survive 
his  immediate  nervous  trouble,  it  is  very  likely  that  disease  of  some 
other  organ  will  carry  him  off.  Much  depends  upon  his  ability  to  reform  ; 
and  no  assurance  can  be  given  that  he  will  recover  until  this  is  accom- 
plished. 

Diagnosis. — The  only  diseases  for  which  alcoholism  may  be  mistaken 
are:  1.  General  paralysis;  2.  Sclerosis,  and  paralysis  agitans ;  3.  Soften- 
ing ;  4.  Dementia. 

1.  General  paralysis  differs  from  delirium  tremens  in  the  fact  that  in  the 
former  the  delusions  are  always  pleasurable  and  exalted.     The  general 
paralytic  is  the  king,  the  capitalist,  the  ruler  of  the  universe ;  the  alco- 
holic patient  is  depressed,  dejected,  and  sad.     These  differences,  taken  into 
consideration  with  the  fact  that  the  patient  suffers  from  anorexia,  that  his 
face  is  flushed,  and  the  conjunctivas  red,  ought  to  settle  the  real  nature  of 
the  trouble.     Anstie1  alludes  to  the  presence  of  acne  as  a  pathognomonic 
sign.     Chronic  alcoholism  may  very  closely  resemble  general  paralysis, 
but  there  is  more  proper  dementia  in  the  latter. 

2.  Sclerosis  and  paralysis  agitans  are  sometimes  confounded  with  chro- 
nic alcoholism  when  there  is  much  disturbance  of   coordination.      The 
tremor  and  incoordination  are  much  greater  during  voluntary  action,  how- 
ever, in  the  first  conditions,  and  there  is  rarely  any  mental  disturbance  in 
either. 

3.  Softening  resembles  chronic  alcoholism,  but  the  paralysis  and  speech 
disturbance  are  much  more  pronounced,  there  generally  being  aphasia,  and 
the  headache  besides  is  quite  different  from  that  of  alcoholism. 

4.  Senile  dementia  may  make  the  diagnosis  somewhat  difficult.     The 
previous  history  of  the  patient,  however,  will  generally  clear  away  any 
doubts  that  may  arise. 

Treatment The  physician's  first  attempt  should  be  to  prevent  the 

patient  from  further  indulging  his  depraved  appetite.  How  this  is  to  be 
accomplished  depends  very  much  upon  his  surroundings,  temperament, 
and  condition.  If  the  attack  arises  during  a  debauch,  I  prefer  to  cut 
off  at  once  the  supply  of  alcohol,  unless  he  is  utterly  prostrated.  If 
the  attack  occurs  after  cessation,  we  may  then  give  small  quantities  of 
stimulants,  and  "  taper  off."  Should  he  be  irritable  and  excited,  immediate 
recourse  to  sedatives  and  hypnotics  should  be  had  (FF.  87,  3,  4,  33, 
39,  23).  I  have  great  faith  in  the  bromides,  lupulin,  or  simple  reme- 
dies of  this  class.  Fifteen  or  twenty  grains  of  the  bromide  of  calcium, 
given  in  a  drachm  of  the  tr.  lupulin  twice  or  three  times  a  day,  is  often 
sufficient  to  quiet  the  nervous  state.  A  good  cathartic  which  shall  increase 
the  action  of  the  liver,  and  hasten  elimination  of  the  alcohol,  is  an  early 

1  Article  on  Alcoholism,  Reynolds's  System,  vol.  ii.  p.  160. 


360  CEREBRO-SPINAL    DISEASES. 

form  of  treatment  which  is  generally  recommended.  Should  the  insomnia 
be  troublesome  or  the  delirium  violent,  we  may  administer  either  the 
bromides,  or  the  mono-bromide  of  camphor  (F.  87),  which  I  make  the 
claim  of  being  the  first  to  use  for  this  purpose.  It  may  be  given  in  pilu- 
lar  form,  made  up  with  confection  of  roses,  in  doses  of  five  grains  every 
hour  until  sleep  is  produced.  The  bromides  of  calcium  or  sodium  in  thirty 
grain  doses  every  two  hours  sometimes  succeed,  or,  better  still,  they  may  be 
combined  with  chloral  hydrate,  so  that  the  patient  shall  take  fifteen  grains 
of  each  every  two  hours  until  the  excitement  subsides.  Cannabis  indica 
(FF.  81,  39)  has  enjoyed  great  popularity  in  the  treatment  of  this  trouble, 
and  should  be  given  in  doses  of  from  one-half  to  one  grain  of  the  extract. 
Should  the  maniacal  excitement  be  intense,  I  know  of  no  better  remedy 
than  morphine  administered  hypodermically,  but  not  by  the  mouth,  as  it 
may  lie  unabsorbed  for  some  time  without  producing  any  effect ;  and  the 
physician  may  be  tempted  to  give  still  more  than  the  ordinary  dose,  when 
to  his  surprise  absorption  takes  place,  and  its  cumulative  action  follows. 
Digitalis  has  been  recommended  in  large  doses,  and  Anstie  preferred  the 
powder  because  the  alcohol  of  the  tincture  interfered  with  the  proper  action 
of  the  drug.  I  am  inclined  to  think  that  the  application  of  digitalis  stupes 
to  the  lumbar  region  and  the  abdomen  favors  kidney  action,  and  does  more 
good  than  when  the  medicine  is  given  by  the  mouth, 

It  is  of  importance  that  the  action  of  the  skin  and  bowels  should  be 
increased.  For  the  first  object,  small  doses  of  tartar  emetic  assist  the 
emunctory  action  of  the  skin,  while  the  compound  jalap  powder  induces 
copious  and  watery  discharges  from  the  bowels.  Cold  to  the  head,  either 
by  ice-bags  or  cloths  wet  with  ice-water,  blisters  to  the  calves,  and  local 
abstraction  of  blood  may  be  resorted  to  in  violent  cases.  As  to  food: 
when  the  worn-out  stomach  refuses  all  ordinary  articles  of  diet,  it  will 
rarely  reject  iced  milk,  which  may  be  given  in  all  cases.  After  a  while 
soups,  nutritious  broths,  or  bouillon  made  from  beef,  or  Valentine's  beef 
juice,  or  Bonlen's  extract  of  beef,  either  of  which  is  preferable  to  the  Liebig 
extract  on  account  of  the  nauseous  taste  of  the  latter,  may  be  given  in  lib- 
eral quantities.  Small  doses  of  carbonic  acid,  seltzer,  or  Apollinaris 
water,  or  coffee  may  be  administered  before  eating,  and  gently  stimulate 
the  stomach,  in  this  respect  taking  the  place  of  the  drams. 

The  patient's  nausea  may  be  corrected  by  the  aromatic  spirits  of  ammo- 
nia, or  bismuth  and  morphine  (FF.  89,  34,  33),  the  latter  in  very  small 
doses. 

In  chronic  alcoholism  the  aim  of  the  physician  should  be  to  restore  the 
normal  action  of  the  viscera ;  to  stop  the  supply  of  drink ;  and  to  freely  admin- 
ister the  various  preparations  of  iron,  quinine,  and  phosphoric  acid,  as 
well  as  cod-liver  oil  (FF.  8,  9,  10,  32,  40,  12).  I  have  found  that  the 
new  preparation  known  as  dialyzed  iron  (F.  11)  is  well  borne  by  the  irri- 
table stomach,  does  not  constipate,  and  is  therefore  an  excellent  remedy. 
This  may  be  given  with  tr.  digitalis  and  tr.  mix  vomica  (F.  90). 


HYDROPHOBIA.  361 


HYDROPHOBIA. 

Synonyms — Rabies  canina;  Paraphobia;  Lyssaphobia  (?). 

The  name  adopted  to  express  that  form  of  nervous  trouble  which  some- 
times follows  the  bite  of  a  rabid  animal  is  an  evident  misnomer,  as  the 
definition  of  the  term  signifies  "a  dread  of  water."  As  this  is  but  one 
symptom,  and  by  no  means  a  constant  one,  the  first  synonym  is  much 
more  expressive  and  appropriate,  and  is  in  every  way  preferable  to  that  in 
general  use. 

Symptoms — 1.  Period  of  Incubation — After  the  receipt  of  the 
bite,  which  may  produce  an  extensive  wound,  or,  as  is  the  case  sometimes, 
an  insignificant  scratch,  a  period  of  time  extending  from  a  few  months  to 
several  years  may  elapse  before  the  appearance  of  the  second  stage.  The 
Avound  may  heal  by  first  intention,  giving  rise  to  no  inconvenience,  or 
there  may  be  redness  and  neuralgic  pain.  A  history  of  this  kind  is 
usually  given  by  the  patient,  and  is  based  upon  an  exaggerated  statement 
of  the  actual  facts,  which  arises  from  a  disordered  imagination,  Avhile  his 
story  of  the  accident  and  of  his  subsequent  symptoms  is  tinctured  with  a 
decided  tlavor  of  romance.  Nervous  derangement  dependent  upon  fear, 
digestive  disorders,  mental  worry,  and  others  of  the  same  category,  gen- 
erally characterize  this  first  stage. 

2.  Period  of  Invasion — At  the  end  of  the  period  of  incubation,  the 
first  alarming  symptoms  noticed  are  those  connected  with  the  cicatrix, 
which  becomes  painful  and  tender,  and  at  the  same  time  there  are  pains 
which  dart  along  the  nerves  in  the  vicinity.    There  are  next  generally  head- 
ache and  a  sense  of  epigastric  oppression,  with  constipation,  broken  sleep, 
and  a  feeling  of  general  discomfort.     At  the  end  of  two  or  three  days, 
during  which  the  patient  suffers  intensely,  we  may  expect  the  appearance 
of  the  next  stage. 

3.  The  Period  of  Development — With  aggravation  of  the  symptoms 
just  enumerated,  we  find  added  thereto  a  sense  of  constriction  about  the 
throat,  irregular  and  quickened  respiration,  rigidity  of  the  muscles  of  the 
neck,  discomfort  in  deglutition,  and  spasms,  which  begin  in  the  muscles  of 
the  throat  and  back  of  the  neck,  and  gradually  invade  those  of  the  back. 
The  spasms  give  rise  to  much  pain,  which  is  sometimes  spinal  and  at  others 
muscular.     The  patient  is  at  this  stage  delirious  and  flighty,  and  gene- 
rally has  delusions  in  which  dogs  play  an  important  part.     The  difficulty 
of  swallowing,  which  next  follows,  is  not  so  great  when  solids  are  taken. 
Fluids,  on  the  contrary,  seem  to  produce  an  aggravation  of  the  spasms, 
and  the  mere  sound  of  splashing  or  trickling  water  will  excite  a  convulsive 
seizure.     To  add  to  the  sufferings  of  the  patient,  there  is  excessive  thirst, 
which  is  very  distressing.     His  face  becomes  dusky,  and  his  eyes  promi- 
nent and  wild.     He  tosses  from  side  to  side  if  placed  in  bed,  the  saliva 
running  from  the  angle  of  the  mouth  in  a  viscid  stream.     Towards  the 
end  of  the  disease  this  secretion  becomes  thicker  and  mixed  with  mucus, 
and  it  collects  in  the  trachea  and  bronchi.     These  symptoms  may  last 


362  CEREBBO-SPINAL    DISEASES. 

two  or  three  days,  while  in  the  mean  time  the  reflex  excitability  becomes 
so  great  as  to  precipitate  a  convulsion  under  the  least  stimulus.  The 
pulse  is  rapid,  the  headache  more  severe,  the  air-passages  become  filled, 
and  respiration  is  greatly  interfered  with.  The  convulsions  are  readily 
produced  by  blowing  upon  the  patient,  or  by  jarring  him,  or  even  by  slum- 
ming the  door.  At  this  stage  he  becomes  partially  unconscious,  is  quite 
delirious,  and  very  much  agitated.  Previous  to  death  there  is  a  marked 
rise  in  the  temperature,  and  in  one  case  I  saw,  the  history  of  which  I  shall 
presently  relate,  the  temperature  rose  to  103°,  and  I  believe  there  was 
even  a  subsequent  rise.  Hammond  considers  that  it  may  often  reach  110°. 

Death  occurs  in  two  or  three  days  in  most  cases,  but  it  may  be  delayed 
a  day  or  two  longer.  Incontinence  of  urine  and  feces  precedes  the  end  ; 
the  immediate  cause  of  death  being  asphyxia  from  spasmodic  stenosis  of 
the  larynx,  or  obstruction  of  the  air-passages  by  mucus.  I  had  the 
privilege  of  seeing  one  case  at  the  request  of  Dr.  Augustus  Viele,  of  the 
Health  Department  of  the  city,  which  was  subsequently  reported  by  Dr. 
Hadden.1 

Through  the  courtesy  of  Dr.  Hadden  and  Deputy  Coroner  Leo,  I  was 
also  enabled  to  observe  the  post-mortem  appearances  of  the  brain  and  cord 
after  the  patient's  death.  Dr.  Hadden  describes  the  case  so  clearly,  that 
I  shall  mainly  use  his  own  words. 

"  On  the  24th  ultimo,  at  8.30  P.  M.,  I  was  called  to  attend  a  young 
man  named  Win.  McCormick,  residing  at  No.  309  East  51st  Street,  a 
native  of  this  city,  aged  2(5  years,  athletic  in  appearance,  of  usually  good 
health,  nervous  temperament,  and  of  moderately  temperate  habits ;  by 
occupation  a  driver  of  an  express-wagon.  He  was  in  bed,  complaining 
of  nervousness,  soreness  in  his  neck  and  throat,  strange  feelings  of  tight- 
ness around  his  chest.  His  countenance  was  anxious,  pupils  of  his  eyes 
were  dilated,  and  his  general  appearance  was  like  one  who  was  in  fear  of 
impending  danger,  and  not  in  extreme  pain.  He  told  me  that  his  throat 
was  so  sore  that  lie  could  not  swallow  anything — not  even  water.  This, 
lie  thought,  was  due  to  some  simple  medicine  he  had  taken,  and  not  to 
any  serious  ailment.  I  noticed  his  throat  was  not  swollen  on  the  outside, 
and  that  his  voice  was  whining,  and  unlike  a  person  suffering  from  any 
ordinary  soreness  within.  I,  however,  examined  his  throat  within,  but 
found  nothing  to  account  for  this  difficulty  ;  it  was  perfectly  healthy  in 
appearance.  His  pulse,  respiration,  and  temperature  were  normal,  ex- 
cepting an  occasional  sigh.  I  observed,  also,  a  little  disposition  to  hack 
and  spit,  but  in  no  way  troublesome.  He  complained  also  of  thirst,  but 
said  lie  could  not  drink,  he  knew,  for  the  very  sight  of  water  made  him  shud- 
der. I  told  him  his  throat  was  not  sore,  and  urged  him  to  try.  He  assented, 
and  water  was  accordingly  brought,  which,  at  sight,  caused  a  violent  spasm, 
lie  threw  himself  around  in  the  bed,  forward  and  backward,  and  told  the 
party  to  take  it  away  at  once,  as  it  would  kill  him.  He  immediately 
afterwards  called  for  the  goblet,  and  said  he  was  very  thirsty  and  must 
drink,  seized  it,  and  with  a  violent  effort  succeeded  in  taking  a  single 

1  Journal  of  Psychological  Medicine,  May,  1870,  p.  80. 


HYDROPHOBIA.  363 

swallow,  which  was  followed  by  a  severe  convulsive  shudder  and  contrac- 
tion of  the  muscles  of  the  neck  and  chest."  Dr.  Hadden  ascertained  the 
fact  that  he  had  been  bitten  by  a  dog,  and  then  inquired  about  the  symptoms 
antecedent  to  his  visit.  "  Wednesday  and  the  two  preceding  days  he  was 
complaining  of  general  lassitude  and  nervousness ;  had  not  been  able  to 
sleep  at  night ;  was  thirsty,  and  had  drunk  a  great  deal  of  water ;  had 
eaten  but  little ;  appetite  very  poor,  and  on  Wednesday  afternoon  he 
seemed  to  be  growing  worse.  He  went  out  upon  the  street,  but  soon  re- 
turned, saying  that  it  was  very  chilly,  and  he  could  not  stand  the  air  at  all. 
While  taking  a  cup  of  tea  at  6  P.  M.  the  same  evening,  he  first  showed 
signs  of  difficulty  in  swallowing.  Shortly  afterwards,  as  he  was  going  to 
the  kitchen,  he  was  met  by  a  draught  of  cold  air,  which  so  staggered  him 
that  he  nearly  fell ;  he  then  went  to  bed,  where  I  found  him.  After 
giving  the  necessary  caution  to  the  family,  I  ordered  fifteen  grains  of 
bromide  of  potassium  to  be  given  every  hour.  I  left,  and  returned  at 
10.30  P.  M.  .  .  .  Found  him  in  about  the  same  condition  I  had  left  him, 
only  his  pulse  was  irregular,  and  his  spasms  more  frequent.  The  saliva 
was  a  little  more  troublesome,  and  he  also  could  not  swallow  without 
great  difficulty.  I  was  called  again  at  2.30  A.  M.,  the  messenger  stating 
that  the  patient  had  become  very  violent,  and  that  they  were  unable  to 
restrain  him.  I  went  immediately.  .  .  .  Found  him  in  a  frightful  state 
of  excitement ;  had  broken  down  the  bed,  and  was  struggling  with  his 
attendants  to  get  at  liberty.  He  was  shouting  and  crying  out  to  them  to 
let  him  go,  and  called  for  water,  which,  when  brought,  he  could  not  drink. 
His  mind  was  clear,  and  he  knew  all  those  around  him ;  was  spitting  a 
viscid  saliva,  but  was  careful  not  to  spit  upon  any  one,  not  even  on  his 
clothes.  It  was  so  abundant  that  his  attendants  were  obliged  to  wipe  it 
from  his  lips.  Dr.  Leavitt  and  myself,  after  viewing  the  case  in  all  its 
aspects,  concluded  to  inject  in  the  tissues  of  the  leg  half  a  grain  of  mor- 
phine and  one-sixty-fourth  of  a  grain  of  atropine  in  solution,  which  was 
done  at  3  A.  31.  by  Dr.  Leavitt.  We  carefully  watched  the  effect  till  3.30 
A.  31.,  when,  his  violence  having  in  no  way  abated,  another  injection  was 
given  in  the  same  part  of  three-eighths  of  a  grain  of  morphine  and  one- 
eighth  of  a  grain  of  atropine,  which  in  some  degree  produced  the  charac- 
teristic effect  of  morphine,  and  very  clearly  the  appearances  of  the  atropine ; 
for,  notwithstanding  he  was  struggling  violently,  the  saliva,  which  had 
been  very  troublesome,  was  completely  dried  up ;  so  much  so  that  the 
patient  remarked  that  he  was  very  thirsty,  and  his  '  mouth  felt  as  if  he  had 
been  chewing  a  brick.'  Fifteen  drops  of  chloroform  were  then  injected,  with 
no  effect  whatever,  unless  to  weaken  his  already  weak  and  frequent  pulse. 
At  4.15  A.M.  three-eighths  of  a  grain  of  morphine  were  again  introduced 
under  the  skin  without  atropine.  This  quieted  the  patient,  so  that  he  was 
easily  restrained,  and  he  remained  in  this  condition  from  4.30  till  10  A.M., 
when  the  effects  had  so  far  passed  off  that  the  attendants  were  alarmed 
at  his  violence  and  the  abundance  of  saliva  that  he  was  spitting  from  his 
mouth.  At  10.15  A.  M.  three-eighths  of  a  grain  of  morphine  in  solution 
were  injected  in  the  tissue  of  the  thigh,  which  served  to  temper  down  the 
increasing  violence  of  the  spasms,  but  did  not  stop  the  flow  of  saliva.  I 
accordingly,  at  10.45  A.  31.,  injected  three-eighths  of  a  grain  of  morphine 
and  one-fortieth  of  a  grain  of  atropine,  which  had  the  desired  effect  of 
producing  the  quieting  effect  of  the  morphine  and  the  specific  effect  of  the 
atropia  on  the  salivary  glands.  The  poisonous  effects  of  the  morphine  and 


364  CEREBBO-SPINAL    DISEASES. 

atropia  were  at  no  time  apparent.     He  died  at  4.15  P.  M.  June  26,  1874, 
about  twenty-four  hours  after  the  first  spasm." 

Dr.  Hammond  saw  the  patient  on  the  morning  of  the  26th,  and  corrobora- 
ted Dr.  Iladden's  diagnosis.  I  saw  him  at  three  o'clock  of  the  same  day,  and 
found  him  lying  upon  the  floor  bound  with  twisted  sheets,  the  ends  of  which 
were  held  by  his  attendants.  He  was  very  violent,  and,  though  there  were 
no  very  marked  convulsions,  he  seemed  to  be  quite  rigid,  and  his  forearms 
were  flexed  during  most  of  the  time.  He  was  semi-comatose,  and  groaned 
occasionally,  but  took  no  notice  of  those  about  him,  and  did  not  speak. 
His  respirations  were  quick,  and  there  was  a  rattling  sound  produced  in 
his  throat  with  each  expiration  and  inspiration.  A  quantity  of  quite  thick 
mucus  and  saliva  was  spat  up  during  my  visit,  and  there  seemed  to  be  a 
very  free  secretion  of  this  substance.  The  pupils  were  widely  dilated,  and 
as  far  as  I  could  judge  there  was  no  marked  elevation  of  temperature.1 

Recent  cases  of  hydrophobia  have  been  reported  by  Francois,8  Edwards,8 
Smith,*  and  Hanscom.5  The  case  of  the  latter  is  so  interesting  and  so 
graphically  detailed,  that  I  shall  take  the  liberty  of  giving  it  in  its  entirety. 

On  the  morning  of  the  20th  of  November  a  good-natured  pet  spaniel, 
which  had  never  been  known  to  snap  at  any  one,  suddenly  and  without 
any  provocation  sprang  at  his  mistress.  His  master  whipped  him,  and 
he  was  left  in  the  cellar  of  the  house  until  the  time  for  his  dinner. 
While  eating  it  in  the  company  of  a  pet  cat,  as  he  had  been  accus- 
tomed to,  without  ever  having  molested  her,  he  suddenly  seized  the  cat 
and  threw  her  across  the  room.  The  owner  reached  out  his  hand  to  catch 
the  dog,  when  the  latter  caught  him  tightly  by  the  wrist  and  inflicted  a 
deep  wound,  biting  him  three  times ;  the  skin  became  lacerated  while 
making  an  effort  to  shake  him  off.  It  was  supposed  at  the  time  that  the 
dog  was  irritable  from  the  whipping  which  he  had  received  in  the  morning, 
and,  as  he  expected  another  for  snapping  at  the  cat,  defended  himself  by 
biting.  Half  an  hour  after,  the  patient  applied  to  me  for  treatment,  and 
believing  it  to  be  too  late  for  excision  or  cauterization  to  be  effective,  and 
as  there  was  no  history  of  hydrophobia,  I  dressed  the  wound  with  a  solu- 
tion of  carbolic  acid.  It  healed  readily,  and  the  patient  attended  to  his 
business  as  usual  in  four  or  five  days.  Soon  after  the  infliction  of  the  bite 
the  dog  disappeared  and  he  did  not  return  for  thirty-six  hours ;  nothing 
could  be  ascertained  of  his  whereabouts  or  of  his  behavior  during  that  time. 
W  lien  he  returned  he  was  very  much  exhausted,  and  had  the  appearance 
ot  having  been  severely  beaten.  From  what  I  can  learn  of  those  who  saw 
him  he  gradually  grew  weaker,  apparently  losing  the  use  of  his  legs,  espe- 
cially the  hind  ones,  which  he  would  drag  after  him.  He  died  quietly, 
with  his  head  in  the  lap  of  his  mistress,  without  having  had  a  convulsion, 
excessive  flow  of  saliva,  or  tremors.  On  the  13th  day  of  January  (fifty- 

'  In  this  case  the  newspapers  were  filled  with  sensational  accounts.of  the  patient's 
illness,  and  an  attempt  was  made  to  prove  that  the  dog  was  not  mad.  It  is  need- 
less to  say  that  such  was  probably  not  the  case,  and  it  is  to  be  regretted  that  the 
dog  was  never  found. 

«  Host.  Mod.  and  Surp.  Journal,  May  17,  1877.      3  Ibid.,  March  15,  1877. 

4  Ibid.,  March  15,  1877.  •  Ibid.,  April  19,  1877. 


HYDROPHOBIA.  365 

four  days  after  the  injury),  the  patient  began  to  have  shooting  pains  in 
the  forearm,  but  not  especially  localized.  They  did  not  radiate  from  the 
cicatrix,  and  there  was  no  change  in  the  appearance  of  the  latter.  On  the 
following  day  the  pain  had  increased  so  much  that  he  required  one-sixth 
of  a  grain  of  morphia  to  relieve  him ;  it  M*as  given  subcutaneously,  and 
was  repeated  the  next  morning.  After  that  there  was  very  little  pain  in 
the  arm,  and  no  appreciable  change  in  the  pulse  or  temperature.  He  was 
despondent,  and  stated  on  the  morning  of  the  loth  that  '  he  felt  sick  and 
used  up  all  over ; '  he  was  obliged  to  go  to  bed  in  the  afternoon,  and  then 
for  the  first  time  began  to  have  some  difficulty  in  swallowing.  This  symp- 
tom was  not  manifested  by  an  attempt  to  drink  water,  but  during  an  effort 
to  swallow  some  herb  tea  which  he  was  accustomed  to  take  when  ill,  and 
which  he  believed  would  relieve  his  bad  feelings.  There  was  no  trismus; 
he  was  quiet  and  inclined  to  doze.  At  5  P.  M.  Dr.  H.  H.  A.  Beach  saw 
the  patient  with  me,  and  agreed  that  the  history  of  the  case  in  connection 
with  the  symptoms  then  existing  indicated  the  probable  development  of 
hydrophobia,  and  an  unfavorable  prognosis  was  given  to  the  patient's 
brother,  who  promised  not  to  communicate  it  to  the  patient  or  his  friends 
until  the  disease  should  be  fully  declared.  His  pulse  at  that  time  was  102, 
and  the  temperature  in  the  axilla  102°  F.,  face  flushed,  tongue  coated. 
The  cicatrix  presented  no  unusual  appearance,  nor  was  it  tender.  A  dark 
room  was  agreeable  to  him,  but  on  raising  the  curtains  the  light  did  not 
disturb  him  in  the  least.  He  was  perfectly  rational,  and  had  some  thirst, 
but  no  sore  throat.  He  made  an  attempt  to  swallow  a  teaspoonful  of  milk, 
but  was  obliged  to  give  it  up  from  the  moment  that  the  fluid  touched  his 
lips.  Immediately  after  this  attempt  unmistakable  spasmodic  contraction 
of  muscles  between  the  chin  and  sternum  was  observed.  Mentally  the 
patient  was  perfectly  clear,  and  not  disturbed  by  the  unsuccessful  attempt 
at  swallowing  fluids,  but  said  he  would  try  it  again  when  he  should  be 
more  thirsty.  This  symptom,  excepting  when  he  swallowed  teaspoonful 
doses  of  medicine,  continued  until  his  death.  He  was  obliged  to  relieve 
his  thirst  by  sucking  ice  and  snow  through  a  napkin.  The  air  from  a  fan 
or  from  adjusting  the  bed-clothing  caused  a  shudder.  Occasional  sighing 
was  noticed  after  the  second  day ;  it  grew  deeper  and  more  frequent  until 
the  end.  When  disturbed  from  any  cause  his  respiration  was  of  a  spas- 
modic character,  so  much  so  at  times  as  to  interfere  with  his  speech. 

On  the  following  morning  (the  16th)  his  pulse  was  96,  and  mild  de- 
lirium first  developed  ;  this  also  continued  until  his  death.  He  was  easily 
controlled  throughout  the  disease.  He  became  very  suspicious  of  the 
people  about  him,  believing  that  they  were  attempting  to  make  him  the 
victim  of  practical  jokes,  then  of  being  poisoned.  One  hallucination  wa* 
continuous  from  the  time  that  the  delirium  first  developed :  he  thought 
that  some  one  had  thrown  a  dirty  powder  on  him,  and  he  was  continually 
making  efforts  to  shake  it  off  from  himself  and  his  clothing.  He  was  also 
very  cross  and  dictatorial,  but  showed  no  disposition  to  snap  or  bite. 

Between  four  and  five  P.  M.  on  the  18th  he  began  to  have  spasmodic 
contraction  of  the  muscles  of  the  chest,  larynx,  and  throat ;  some  of  them 
lasted  nearly  a  minute,  and  prevented  him  from  taking  an  inspiration. 
He  also  had  a  profuse  discharge  of  saliva  sufficient  to  wet  his  clothing 
through  from  his  chin  down  to  his  hips.  The  spasmodic  contractions  con- 
cerned in  respiration  exhausted  him  rapidly,  and  he  died  quietly  at  8.15, 
while  sitting  up  in  a  chair.  This  position  became  necessary  from  the  fact 
that  he  could  not  lie  on  his  side,  and  if  on  his  back  the  saliva  accumulated 


366  CEREBRO-SPINAL    DISEASES. 

so  rapidly  that  it  obstructed  his  respiration.  For  the  last  twenty  minutes 
before  his  deatli  there  was  no  spasm.  He  lived  five  days  after  the  fir>t 
general  symptom.  At  no  time  was  he  disturbed  by  the  sound  of  ringing 
bells  or  running  water.  Morphia  in  one-fourth-grain  doses,  and  chloral  and 
bromide  of  potassium  in  fifteen-grain  doses  of  each  at  the  same  time  were 
given  as  needed.  Anaesthetics  were  not  required.  At  the  solicitation  of 
his  friends  he  was  allowed  to  take  a  pill,  the  prescription  for  which  was 
said  to  be  one  hundred  years  old  and  to  have  cost  originally  five  hundred 
pounds.  It  had  the  reputation  of  curing  and  preventing  many  cases  of  the 
disease.  No  change  in  his  symptoms  could  be  attributed  to  its  action,  nor 
could  its  composition  be  ascertained.  It  was  given  as  a  placebo,  on  the 
chances  that  an  hysterical  element  existed  in  this  case  ;  that  whatever 
offered  encouragement  to  the  patient  without  the  possibility  of  injury  in 
his  hopeless  condition  was  justifiable,  but  so  far  as  the  evidence  furnished 
by  one  case  is  of  value  its  inefficacy  was  demonstrated.  The  permission 
of  the  friends  for  an  autopsy  could  not  be  obtained.  The  particular  symp- 
toms of  the  disease  which  were  not  observed  in  the  dog  when  seen  might 
have  existed  during  the  thirty-six  hours  that  he  was  absent. 

The  proximity  of  the  wound  to  the  ulnar  nerve  and  its  character 
(punctured  and  lacerated)  suggested  the  consideration  of  tetanus  as  an 
explanation  of  the  symptoms;  the  latter  seemed  to  be  fairly  excluded, 
however,  on  the  ground  that  delirium  was  continuous  from  the  third  day 
of  the  attack,  and  that  at  no  time  did  trismus  or  any  other  form  of  tonic 
spasm  exist ;  the  profuse  discharge  of  saliva  was  also  corroborative  of  this 
view.  The  unquestionable  existence  of  repeated  attacks  of  laryngeal 
spasm  ;  the  fact  that  the  symptoms  developed  after  a  considerable  interval 
had  elapsed  from  the  date  of  the  injury ;  that  for  three  hours  previous  to 
his  death,  and  after  he  became  wholly  unconscious,  marked  spasms  of  the; 
chest  and  throat  occurred  at  intervals  of  from  three  to  five  minutes ;  that 
death  occurred  as  a  result  and  within  five  days  following  the  development 
of  symptoms  characteristic  of  the  disease,  reasonably  offsets  a  theory  that 
the  hydrophobia  symptoms  were  simulated  by  an  hysterical  man. 

In  Smith's  case  the  period  of  incubation  was  about  two  months,  and  the 
paroxysms  were  ushered  in  by  vomiting,  fear  of  water,  and  febrile  symp- 
toms. On  the  third  day  of  the  disease  he  became  delirious,  and  on  the 
fourth  died.  The  sound  made  by  the  patient,  which  is  so  often  compared 
to  the  bark  of  a  dog,  was  likened  by  the  author  to  that  made  by  a  croupy 
child.  In  Edwards's  case,  the  period  of  incubation  was  about  five  months. 
The  injury  was  insignificant,  but  with  the  invasion  of  the  disease  there 
was  pain  in  the  cicatrix  which  extended  up  the  arm.  In  this  patient  there 
was  also  dread  of  fluids,  especially  water.  On  the  second  day  the  convul- 
sions began.  The  same  day  she  spat  up  bloody  mucus.  At  the  end  of 
sixty  hours  from  the  first  local  pain  she  died. 

Causes — The  circumstances  which  concern  the  etiology  are  still 
enshrouded  in  mystery.  Hammond  is  of  the  opinion  that  rabies  may  be 
communicated  by  a  dog  that  is  not  mad,  and  brings  forward  several  cases  to 
prove  his  theory.  I  cannot  agree  with  him,  for  it  seems  to  me  highly  im- 
probable that  there  should  be  so  few  cases  of  this  disease  if  the  bite  of  a 
non-rabid  animal  can  inoculate  an  individual.  Bouley  states  that  in  no 
way  can  the  disease  be  transmitted  other  than  by  inoculation  with  the  saliva. 


HYDROPHOBIA.  367 

In  this  statement  he  receives  the  endorsement  of  Magendie  and  others. 
Another  point  remains  to  be  answered,  and  this  is  in  regard  to  the  trans- 
mission of  virus  from  one  person  to  another  without  the  second  person 
being  bitten.  Fleming  has  given  an  example  which  shows  that  this  may 
take  place. 

In  the  spring  of  the  present  year  I  was  subpoenaed  to  serve  as  a  juryman 
in  the  case  of  a  boy  who  had  died  of  rabies.  At  about  the  same  time 
another  death  occurred  which  the  attending  physician  said  was  simply  the 
result  of  fear,  and  not  of  hydrophobia.  A  careful  inquiry  and  examination 
of  witnesses  revealed  the  following  history,  which  I  think  proved  beyond 
a  doubt  that  the  cause  of  death  in  both  cases  was  the  bite  of  a  rabid  cat. 
This  cat  had  found  her  way  into  a  stable  on  Thirty -fourth  Street,  and  had 
bitten  a  horse.  This  horse  afterwards  died  in  convulsions,  and  from  all  I 
could  leurn  the  cause  of  death  was  hydrophobia.  In  an  adjoining  yard  the 
cat  bit  one  of  the  boys,  who  also  died,  and  a  few  days  afterwards  bit  the 
other  boy,  whose  inquest  we  attended.  Both  of  these  victims  died  within 
a  short  time  of  each  other.  In  one  of  these  cases  there  was  but  a  slight 
scratch. 

Morbid  Anatomy  and  Pathology Clifford  Albutt,1  Meynert, 

Elder,2  and  Hammond3  have  all  made  autopsies,  and  still  there  seems  to  be 
very  little  light  thrown  upon  the  pathogeny  of  the  disease.  Hammond 
found  granular  degeneration  of  the  nerve-cells  of  the  cortical  layer  of  the 
brain,  and  extravasations  of  blood  in  the  medulla  with  destruction  of  cell- 
contents.  The  gray  matter  of  the  nuclei  of  the  pneumogastric  and  hypo- 
glossal  nerves  had  undergone  granular  degeneration.  Albutt  found  en- 
largement of  vessels  in  the  cerebral  convolutions,  pons,  medulla,  and  spinal 
cord,  and  granular  disintegration.  Elder  found  absolutely  nothing ;  and 
Lockhart  Clarke,  who  examined  parts  of  the  brain,  medulla,  and  cord, 
found  the  utter  absence  of  any  lesion. 

Kolesnikoff4  reported  the  appearance  of  the  nervous  centre  in  ten  dogs 
that  had  died  of  hydrophobia.  "  The  parts  examined  included  the  hemi- 
spheres, corpora  striata,  thalami  optici,  cornua  ammonis,  cerebellum,  me- 
dulla oblongata,  spinal  cord,  the  sympathetic  and  vertebral  ganglia.  The 
most  marked  changes  were  observed  in  the  two  latter,  and  were  as  fol- 
lows :  1.  The  vessels  were  enlarged,  choked  with  red  blood-corpuscles  ; 
occasionally,  extravasated  red  corpuscles  and  round  indifferent  elements 
(probably  white  corpuscles)  were  found  in  the  perivascular  spaces.  The 
walls  of  the  vessels  were  here  and  there  filled  with  hyaloid  masses  of  vari- 
ous forms,  which  occasionally  extended  into  the  lumen  of  the  vessels,  and 
closed  this  as  a  thrombosis  would.  Not  far  from  these  masses  collections 
of  white  and  red  blood-corpuscles  could  be  observed,  the  latter  deprived  of 
color.  They  could  be  seen  also  in  all  stages  of  metamorphosis  into  hya- 

1  Med.  Record,  i.  22.  *  Dis.  of  Nervous  System,  pp.  654-660. 

3  Brit.  Med.  Journ.,  vol.  ii.  1871. 

4  Centralblatt  fur  Med.  Wissen.,  No.  50,   1875.      Abst.  Phil.  Med.  Times, 
Feb.  5,  1876. 


368  CEREBRO-8PINAL    DISEASES. 

loid  globules.  2.  In  the  pericellular  spaces  of  the  nerve-cells  could  be 
observed  collections  of  round  indifferent  elements,  whose  penetration,  to 
the  number  of  five  to  eight  or  even  more,  pressed  out  the  protoplasm  of 
the  cells.  This  penetration  of  the  elements  spoken  of  was  frequently  suffi- 
cient to  change  the  form  of  the  nerve-cells,  giving  them  at  different  times 
a  sac -formed,  bulged,  or  flattened-out  appearance.  Further,  the  nucleus 
was  sometimes  pushed  towards  the  periphery  of  the  cell  and  surrounded 
by  many  round  elements.  In  other  cases,  only  groups  of  round  (indif- 
ferent) bodies  could  be  observed  in  place  of  the  nerve-cells.  In  isolated 
nerve-cells  the  changes  described  could  also  be  observed." 

The  body  of  Dr.  Hadden's  patient  was  examined  by  the  deputy  coroner 
and  several  physicians,  among  whom  were  Drs.  Clymer,  Hammond,  Cross, 
and  myself.  The  calvarium  was  removed,  and  great  congestion  of  the 
meningcs  and  brain  was  observed.  The  sinuses  were  much  engorged,  lnit 
there  was  very  little  effusion  either  upon  the  surface  of  the  brain  or  in  the 
ventricles.  The  lower  surface  of  the  brain  appeared  to  be  slightly  softened 
in  patches,  but  there  was  nothing  else  to  attract  attention,  except  it  might 
perhaps  have  been  a  great  hardness  of  the  pituitary  body.  Dr.  Hammond's 
microscopical  examination  was  subsequently  made,  and  I  have  already 
alluded  to  its  results.  The  internal  viscera  were  all  hypercemic,  but 
there  were  no  other  morbid  appearances.  The  larynx  and  trachea  were 
found  to  be  very  much  injected,  and  the  latter  contained  a  quantity  of 
frothy  mucus.  Dr.  Willis  has  found  the  blood  of  persons  who  have  died 
from  this  disease  to  be  very  fluid  and  of  a  dark  color. 

The  question  to  be  answered  is,  whether  this  affection  is  a  primary  dis- 
order of  the  nervous  centres  or  whether  it  is  the  result  of  general  blood- 
poisoning.  I  am  inclined  to  accept  the  latter  theory,  as  the  array  of  facts 
is  too  meagre  to  permit  any  positive  assertion  as  to  its  nervous  origin. 
Like  other  disorders,  not  essentially  nervous,  there  is  a  period  of  inocu- 
lation, of  incubation,  of  invasion,  and  development.  I  think,  then,  that 
in  this  respect  this  disease,  as  well  as  tetanus,  resembles  closely  some 
of  the  exanthemata.  Hammond  compares  the  disease  with  tetanus,  epi- 
lepsy from  reflex  causes,  and  other  neuroses  of  the  same  description,  and 
is  inclined  to  consider  it  a  nervous  disease  per  se. 

Diagnosis — It  is  important  to  bear  in  mind  the  fact  that  a  great 
many  so-called  cases  of  hydrophobia  are  not  this  disease  at  all,  and  that 
certain  forms  of  hysteria  bear  to  it  a  close  resemblance.  Fright  may 
act  so  powerfully  upon  the  nervous  system  that  a  train  of  symptoms  may 
be  produced  very  much  like  those  of  the  genuine  affection.  A  case  of  this 
kind  occurred  at  Bellevuc  Hospital  a  year  or  two  ago,  in  which  the  symp- 
toms counterfeited  those  of  the  real  disease  in  every  respect,  and  the  patient 
finally  died.  It  was  found  that  the  individual  had  not  only  never  been 
bitten,  but  that  he  actually  died  of  fear,  his  imagination  having  been 
stimulated  by  the  sensational  articles  in  the  newspapers.  Dr.  J.  W.  S. 
Arnold,  of  the  University,  who  examined  the  brain  and  cord,  was  unable 
to  find  the  slightest  indication  of  any  morbid  change.  The  only  other 


HYDROPHOBIA.  369 

conditions  from  which  we  may  be  required  to  make  a  differential  diagnosis 
are  tetanus,  Calabar  bean,  and  picro toxin  poisoning.  In  the  former  there 
are  many  points  of  resemblance,  and  occasionally  a  dread  of  liquids  and 
a  difficulty  in  swallowing.  In  tetanus,  however,  the  risus  sardonicus 
is  present,  the  spasms  are  tonic,  and  there  is  opisthotonos,  and  the  mind 
is  clear  to  the  last. 

In  poisoning  by  both  agents,  to  which  I  have  alluded,  the  rapidity  of 
their  action  is  conspicuous,  and  a  dose  of  either  would  carry  the  patient 
off  in  a  few  hours,  more  or  less.  In  picrotoxin  and  Calabar  bean  poisoning 
there  are  many  of  the  symptoms  of  hydrophobia,  such  as  clonic  spasms, 
frothing,  rise  of  temperature  ;  but  no  dread  of  water,  nor  delirium. 

Epilepsy  may  resemble  hydrophobia,  but  it  is  only  when  the  attacks  are 
numerous  and  closely  connected  that  such  a  mistake  could  possibly  occur. 

Marbaix1  "  gives  a  case  of  epileptiform  convulsions  more  or  less  resem- 
bling hydrophobia,  in  a  man  who  had  been  bitten  four  days  before  by  a 
cut ;  they  were  accompanied  by  delirium  and  hypersesthesia  of  the  optic 
nerve,  a  stray  light  thrown  across  his  eyes  causing  a  convulsive  attack. 
The  shortness  of  the  incubation,  the  blueness  of  the  face,  without  the 
*  vultueuse'  expression  characteristic  of  hydrophobia,  the  delirium,  and  the 
melancholy,  not  exalted,  condition,  combined  with  a  history  of  an  epileptic 
attack  a  year  before,  prevented  the  case  being  looked  upon  as  one  of  true 
hydrophobia." 

Prognosis — In  true  hydrophobia  it  is  very  bad.  I  believe  there 
never  have  been  more  than  one  or  two  genuine  cures  reported ;  and  if  others 
have  been  claimed,  it  is  probable  that  no  rabies  existed,  but  that  the  affec- 
tion described  was  simply  hysteria.  The  chance  of  inoculation  seems  to 
be  a  matter  of  interest,  for  of  the  reported  cases  in  which  individuals  have 
been  bitten,  it  has  been  found  that  about  two-thirds  of  them  subsequently 
developed  symptoms  of  rabies. 

Treatment — We  rarely  see  these  patients  until  actual  evidences  of 
madness  have  appeared.  If,  however,  we  are  fortunate  enough  to  be  called 
to  the  individual  immediately  after  he  has  been  bitten,  we  may  either  incise 
or  cauterize  the  wound.  It  is  well  to  ligate  the  limb  as  soon  as  possible, 
and  then  remove  en  masse  the  piece  of  the  muscle  which  has  been  pene- 
trated by  the  teeth  of  the  rabid  animal.  Various  writers  recommend  the 
cupping-glass,  which  should  be  applied  to  the  excised  part  till  it  abstracts 
several  ounces  of  blood  from  the  wound.  A  pencil  of  nitrate  of  silver  may 
be  thrust  into  the  punctures  made  by  the  teeth  of  the  dog  until  they  are 
well  cauterized,  and  a  strong  solution  (3u'-oj)  should  be  applied  afterwards 
by  means  of  a  piece  of  folded  linen,  \vhich  is  to  be  covered  by  oil  silk. 

I  am  convinced  that  no  remedy  can  do  good  where  the  disease  has 
already  appeared,  except,  perhaps,  curare,  which  has  been  tried;  and  in 
one  case,  where  it  was  prescribed  by  Dr.  Austin  Flint,  Sr.,  it  is  said  to 
have  saved  the  patient's  life. 

The  case  must  be  desperate,  however,  when  this  powerful  substance  is 

1  Presse  M6d.  Beige,  1869,  237. 
24 


370  CEREBRO-SPINAL    DISEASES. 

resorted  to,  for  its  preparation  is  not  always  the  same,  and  no  two  speci- 
ments  are  of  the  same  strength.  It  lias  been  injected  hypodermically  in 
doses  of  one  grain. 

Oftenberg1  reports  the  cure  of  a  girl  of  eighteen.  She  received  at  first 
hypodermic  injections  of  morphine  and  chloroform,  but  there  was  no  im- 
provement in  her  condition.  Seven  hypodermic  injections,  aggregating 
three  grains  of  curare,  were  afterwards  given  in  the  course  of  six  hours.  The 
muscular  disturbance  subsided  at  once,  and  there  was  ultimate  recovery. 
The  convulsions  were  succeeded  by  paralysis,  which  gradually  disappeared. 

Hot  baths  have  been  recommended,  but  I  cannot  find  that  they  have 
ever  cured  a  case  of  this  kind. 


HYSTERIA. 

Definition It  would  be  almost  impossible  to  give  a  concise  defini- 
tion of  this  most  protean  of  nervous  affections,  for  it  simulates  a  multitude 
of  onranic  and  functional  diseases  so  perfectly,  that  the  task  of  considering 
it  in  any  systematic  manner  would  be  attended  with  great  difficulty.  The 
nervous  system  in  this  respect  is  like  the  "  general  utility"  actor.  It 
plays  the  most  varied  parts.  Sometimes  we  are  presented  with  a  hemi- 
plegia  or  paraplegia,  and  at  others  witli  contractures  which  seem  to  be  the 
result  of  organic  disease,  so  permanent  and  intractable  do  they  appear. 
Convulsions,  anaesthesia,  urinary  and  other  troubles  of  a  more  or  less 
grave  character,  swell  the  list,  until  we  are  almost  inclined  to  look  upon 
it  as  a  "disease  of  the  Devil,"  and  cease  to  wonder  at  the  credulity 
and  superstition  of  those  who  believe  in  demoniac  possession  and  witch- 
craft. Confining  ourselves  as  closely  to  the  subject  as  possible,  we  con- 
clude that  hysteria  is  a  disease  of  an  emotional  character  chiefly  among 
women,  in  which  the  symptoms  are  rarely  the  same  in  any  two  instances, 
but  among  a  large  number  of  cases  there  can  be  noticed  a  certain  simi- 
larity. 

Symptoms. — These  symptoms  may  be  grouped  as  sensorial,  moto- 
riV//,  and  visceral.  Sensorial  symptoms  are  of  three  kinds :  hyperaesthetic, 
ana-sthetic,  and  mental.  Hypercesthesia,  though  much  more  common  than 
ana-sthesia,  is  not  so  marked.  Large  areas  of  hypersesthesia  may  be  de- 
tected by  careful  examination,  though  the  patient  usually  saves  this 
trouble,  for  she  calls  attention  to  the  weight  of  her  clothes,  the  pressure  of 
some  fold  of  her  underwear,  or  the  contact  of  some  very  light  substance 
which  is  pronounced  unbearable.  The  external  organs  of  generation  are 
extremely  sensitive,  and  the  slightest  touch  of  the  finger  or  speculum  pro- 
duces a  spasm  and  great  agony.7  Coition  is  impossible,  and  one  patient 

1  Wion.  Med.  Presse,  1876,  No.  1. 

2  1  have  been  able  to  stop  an  hysterical  paroxysm  by  firm  pressure  upon  the 
ovary.     Light  pressure  greatly  aggravated  the  patient's  discomfort.     Other  ob- 
servers have  called  attention  to  this  phenomenon,  among  them  Charcot. 


HYSTERIA.  371 

called  my  attention  to  a  horrible  shooting  pain  which  occurred  whenever 
her  husband  approached  her.  Hypersesthesia  about  the  nipples,  at  the 
end  of  the  coccyx,  and  in  other  parts  of  the  body,  is  alluded  to  by  vari- 
ous writers.  Charcot  has  directed  attention  to  the  prominence  of  these  ; 
and  Briquet  has  described  fixed  pains  of  the  abdomen  which  he  called 
caelalgice,  and  of  450  cases  he  found  200  presenting  this  symptom.  They 
were  hypogastric  and  iliac,  but  more  commonly  the  latter.  These  have 
sometimes  been  mistaken  for  the  pain  of  peritonitis;  there  is,  however, 
no  tenderness,  but  simply  superficial  elevation  of  sensibility.  The  patient 
often  calls  attention  to  vague  pains  in  different  parts  of  the  body,  of  a 
transitory,  and  sometimes  permanent  character.  She  complains  of  strong 
light  and  loud  noises,  and  insists  upon  perfect  quiet,  although  she  will  her- 
self talk  and  cry  in  a  very  noisy  manner.  All  of  her  pains  are  increased 
when  her  attention  is  concentrated  upon  them,  but  when  her  mind  is 
diverted  she  will  bear  very  rough  treatment  without  complaint. 

Neuralgic  pain,  a  familiar  variety  being  the  clavus  hystericus,  is  a  com- 
mon form  of  complaint.  Various  local  pains  are  also  experienced,  and 
these,  among  others,  include  alterations  in  sensibility  which  simulate  lum- 
bago ;  indeed,  a  very  constant  hysterical  complaint  is  backache,  which  the 
patient  generally  attributes  to  the  kidneys.  A  most  interesting  form  of 
hysterical  dysaesthesia  has  received  mention  from  Skey,  Paget,  and  others, 
and  is  very  often  mistaken  for  rheumatism.  The  joints  are  neither  swollen 
nor  red,  however.  Moriz  Meyer,1  in  an  interesting  article  upon  the  sub- 
ject, gives  the  leading  points  in  diagnosis  as  follows :  "  1.  The  neuralgia  is 
of  a  diurnal  form  entirely.  2.  Light  pressure  of  joints  produces  pain,  but 
comparatively  violent  handling  is  not  at  all  painful.  3.  The  temperature 
of  the  affected  joint  undergoes  variations.  4.  There  is  no  loss  of  sub- 
stance of  the  muscles  of  an  unsound  limb.  5.  The  cure  is  usually  spon- 
taneous." The  mental  disturbances  are  of  the  most  interesting  character, 
whether  expressed  by  transient  emotional  excitement  or  apparent  pro- 
longed unconsciousness.  Examples  of  the  lighter  grades  are  too  familiar 
to  need  description,  and  it  is  only  necessary  to  allude  to  the  outbursts  of 
immoderate  laughter  or  crying  which  occur  when  there  is  no  reason  for 
either  emotional  elation  or  depression.  Such  individuals  may  indulge  in 
laughter  at  church  or  at  a  funeral,  and,  while  perfectly  aware  of  the  im- 
propriety of  their  conduct,  will  be  utterly  unable  to  restrain  themselves. 
Illusions,  hallucinations,  and  even  delusions  are  evidences  of  a  very  irri- 
table condition  of  the  nervous  centres,  as  are  ecstasy  and  mental  excite- 
ment of  various  kinds,  such  as  belief  in  impending  calamity  or  death. 
The  involuntary  use  of  foul  words  and  gestures,  and  a  remarkable  eccen- 
tricity of  behavior,  are  additional  suggestions  of  a  disordered  state  of  the 
emotions.  Wynter,2  in  his  excellent  little  book,  thus  alludes  to  a  condi- 
tion which,  after  all,  is  but  a  manifestation  of  hysteria. 

1  Berliner  Klin.  Woch.,  1874,  No.  26. 

2  Borderland  of  Insanity,  p.  3. 


372  CEREBRO-SPINAL    DISEASES. 

"There  is  a  terrible  stage  of  consciousness  in  which,  unknown  to  any 
other  human  being,  an  individual  keeps  up  as  it  were  a  terrible  hand-to- 
hand  conflict  with  himself  when  he  is  prompted  by  an  inward  voice  to  use 
disgusting  words,  which,  in  his  sane  moments,  he  loathes  and  abhors. 
These  voices  will  sometimes  suggest  ideas  which  are  diametrically  opposed 
to  the  sober  dictates  of  his  conscience.  In  such  conditions  of  mind,  prayers 
are  turned  into  curses,  and  the  chastest  into  the  most  libidinous  thoughts."1 
The  will  is  quite  weak,  while  the  emotions,  far  from  being  held  in 
abeyance  to  the  extent  which  they  are  in  health,  respond  to  trivial  id«  a- 
tional  impressions.  The  hysterical  person  firmly  believes  herself  to  be  the 
subject  of  various  disorders  of  a  greater  or  less  serious  character;  is  hope- 
less ;  believes  in  a  speedy  fatal  termination  of  her  imaginary  trouble  ;  and 
can  only  be  convinced  of  her  mistake  by  fear  of  the  remedy  suggested,  or 
by  some  strong  appeal  to  her  appetite  or  comfort.  While  in  a  state  which 
may  sometimes  appal  the  observer,  the  patient  declares  her  inability  to 
walk.  If,  however,  some  powerful  excitement  be  produced,  such  as  an 
alarm  of  fire,  she  quickly  recovers  the  use  of  her  legs.  I  have  recently 
seen  a  most  interesting  case  of  hysterical  torticollis,  in  which  the  patient 
refused  to  turn  or  raise  her  head.  I  quietly  seated  myself  at  her  other 
side,  and  engaged  her  attention  so  fully  that  after  a  while  she  turned  her 
head  and  talked  for  some  time;  and  it  was  only  when  I  referred  to  the 
subject  of  her  troubles  that  she  quickly  resumed  her  original  position,  and 
I  could  not  persuade  her  to  change  it.  She  may  at  times  believe  that  she 
is  deaf  or  dumb,  and  remain  in  such  an  uncomfortable  condition  for  years, 
punishing  not  only  herself,  but  making  all  about  her  uncomfortable. 

Hysterical  anaesthesia  has  received  a  great  deal  of  attention  of  late 
years  from  the  French  observers,  especially  from  Charcot  and  Briquet,  as 
well  as  I'iorry  and  Gendrin.  Briquet*  has  found  that  this  condition  occurs 
more  frequently  on  the  left  than  upon  the  right  side.  It  may  be  superfi- 
cial or  deep,  even  affecting  the  muscles  and  bones.  Reynolds  has  found 
it  limited  often  to  the  back  of  the  hand  or  foot,  or  alxmt  the  mouth  and 
nose.  The  vaginal  canal  and  the  lining  mucous  membrane  of  the  mouth 
are  also  places  where  there  may  be  loss  of  sensation.  Hysterical  anaes- 
thesia not  rarely  follows,  or  comes  on  during  a  convulsive  attack,  and 
lasts  for  a  variable  time.  It  may  subside  in  a  few  hours,  or  continue  for 
months  at  a  time.  During  its  existence  the  most  violent  stimuli  will 
fail  to  restore  sensibility  ;  and  I  have  often  used  powerful  counter-irri- 
tants, electricity,  or  even  the  hot  iron,  without  any  response  whatever. 
The  loss  of  sensation  may  extend  more  deeply,  so  that  the  underlying 

1  Hysterical  girls  and  women  occasionally  evince  a  depraved  appetite,  eating 
all  sorts  of  extraordinary  things.  The  school-girl  habit  of  eating  slate-pencils  is 
an  example  of  this.  I  have  personally  observed  this  evidence  of  hysteria  on 
many  occasions.  A  young  lady  recently  under  treatment  ate  enormous  quantities 
of  nutmegs.  The  morbid  apjwtite  of  pregnancy  is  probably  an  hysterical  dis- 
order. 

f  Trai(6  Clinique  ct  Th6rapeutique  de  I'Hystfcrie,  Paris,  1859. 


HYSTERIA.  373 

muscles  may  be  utterly  without  sensation.  This  peculiarity  probably  ex- 
plains the  insusceptibility  to  pain  spoken  of  by  Carre"  de  Montegeron.  The 
Janseniste  or  Convulsionnaires  "  became  so  wrought  up  by  religious  ex- 
citement that  they  fell,  twenty  or  more  at  a  time,  into  violent  convulsions, 
and  demanded  to  be  beaten  with  huge  iron-shod  clubs,  in  order  to  be 
relieved  of  an  unbearable  pressure  upon  the  abdomen.  One  of  the  bro- 
thers Marion  felt  nothing  of  the  thrusts  made  by  a  sharp-pointed  knife 
against  his  abdomen." 

Not  only  may  there  be  analgesia,  but  loss  of  appreciation  of  heat  or 
cold,  and  the  surface  may  become  blanched  and  white,  and  the  skin  even 
bloodless.  Brown-Sequard  has  demonstrated  the  absence  of  blood ;  a  fact 
which  has  an  historical  interest  in  connection  with  the  tests  of  the  early 
religious  enthusiasts.  Charcot  alludes  to  the  epidemic  of  St.  Medard, 
when  the  cut  of  a  sword  failed  to  produce  any  flow  of  blood.  The  tem- 
perature of  the  anaesthetic  spot  is  sometimes  lowered  two  or  three  degrees, 
and  varies  in  different  regions.  There  may  be  anaesthesia  of  the  mucous 
membranes  of  the  mouth,  the  pharynx,  and  larynx;  or  the  organs  of  spe- 
cial sense  may  be  implicated,  and  a  resulting  amaurosis,  amblyopia,  or  deaf- 
ness ensue.  In  a  paper  upon  "Hysterical  Affections  of  the  Eye,"  by  Dr. 
Geo.  C.  Harlan,1  of  Philadelphia,  attention  is  directed  to  retinal  anaesthesia 
and  various  hysterical  disorders  of  an  interesting  character. 

"Almost  any  derangement  of  vision  may  be  counterfeited.  A  little  girl 
of  eight  years  complained  that  every  object  that  she  looked  at  seemed 
covered  with  diagonal  white  lines,  the  direction  of  which  she  indicated 
with  her  finger.  As  the  ophthalmoscope  revealed  a  normal  fundus,  a 
favorable  prognosis  was  given.  This  was  made  more  positive  the  next 
day,  when  the  white  lines  changed  to  blue,  and  was  justified  by  the  early 
disappearance  of  the  difficulty. 

"  In  the  second  class  of  cases  we  have  more  or  less  retinal  anaesthesia, 
with  anomalous  and  variable  symptoms,  changing,  perhaps,  at  each  exami- 
nation. 

"  In  the  third  class  of  cases  the  parts  affected  have  been  the  retina,  the 
muscle  of  accommodation,  the  external  muscles  of  the  eyeball,  and  the 
elevator  of  the  upper  eyelid. 

"  It  is  not  veiy  uncommon  to  meet  with  patients  who  have  apparently 
perfect  eyes  and  full  acuity  of  vision,  but  who  say  that  the  test  letters  be- 
come blurred  and  unrecognizable  after  they  have  looked  at  them  for  a  few 
seconds.  That  this  is  due  to  an  exhaustion  of  the  sensibility  of  the  retina, 
which  disables  it  from  the  sustained  performance  of  its  function,  and  not 
to  an  irregular  action  of  the  accommodation,  is  shown  by  the  fact  that  it 
persists  when  the  eye  is  fully  under  the  effects  of  atropia." 

Taste  and  smell  are  sometimes  impaired,  so  that  there  is  a  greater  or 
less  extensive  loss  or  a  perversion,  the  patient  declaring  that  natural  odors 
are  reversed,  or  that  articles  of  food  are  tasteless. 

1  Phil.  Med.  and  Surg.  Rep.,  August  12,  1876. 


374  CEREBRO-SPINAL    DISEASES. 

The  motorial  symptoms  are  numerous,  and  may  be  either  of  a  sthenic 
or  asthenic  character.  The  simplest  include  spasms,  violent  gesticulations, 
and  contractures :  the  more  obstinate,  paralysis  of  either  a  hemiplegic, 
or  paraplegic,  or  even  a  local  form,  and  chorea  and  convulsions,  as  well  as 
various  kinds  of  muscular  incoordination.  The  individual  may  assume 
the  most  painful  positions,  the  limbs  being  rigidly  flexed  or  extended,  and 
the  face  distorted  by  grimaces  of  the  most  absurd  description.  Sometimes 
there  is  torticollis,  or  spasm  of  some  small  group  of  muscles,  or  the  muscular 
rigidity  may  even  amount  to  opisthotonos,pleurothotonos,  or  emprosthotonos, 
and  these  forms  of  trouble  are  much  more  marked  in  conditions  of  hystero- 
epilepsy  and  hystero-catalepsy.  The  dependence  of  these  motorial  pheno- 
mena upon  reflex  excitement  is  their  marked  feature,  slight  peripheral 
irritations,  uterine  trouble,  or  sexual  excitement  of  any  kind,  often  being 
the  origin  of  the  affection. 

The  pharynx,  larynx,  and  not  rarely  the  stomach  are  implicated,  so 
that  difficulty  of  swallowing,  loss  of  speech,  and  vomiting  are  resulting 
phenomena.  Hysterical  attacks  of  a  convulsive  character  are  met  with 
sometimes,  when  the  patient  is  apparently  unconscious,  but  is  in  reality 
not  at  all  so.  There  is  slow  respiration,  which  is  scarcely  perceptible,  and 
small  weak  pulse.  The  legs  and  arms  may  be  wildly  thrown  about,  or 
rigidly  extended,  and  there  may  be  opisthotonos,  while  the  skin  is  livid, 
and  maybe  bathed  in  perspiration.  A  lighter  grade  of  attack  is  frequently 
seen,  in  which  the  patient,  after  a  period  of  excitement,  screams,  and  falls 
to  the  floor  (being  very  careful  not  to  hurt  herself) ;  her  muscles  become 
contracted;  she  breathes  heavily,  froths  at  the  mouth,  talks  incoherently, 
and  berates  those  about  her.  She  may  cry,  and  in  doing  so  sobs  violently, 
sometimes  catching  her  breath  in  an  alarming  manner,  frightening  her 
attendants  and  attracting  sympathy.  If  left  to  herself  and  not  noticed, 
she  may  fall  asleep  or  gradually  recover.  The  patient  looks  about  the 
room  during  the  attack,  and  is  undoubtedly  conscious  of  what  transpires. 
One  significant  mark  of  hysteria,  previously  alluded  to,  is  that,  however 
much  the  patient  throws  herself  about,  she  is  always  careful  not  to  do  her- 
self injury.  Pomine1  was  among  the  first  to  describe  hysterical  contrac- 
tures, and  later  Gorget  related  a  case  of  hysterical  flexion  of  the  thigh 
upon  the  pelvis  which  was  supposed  to  be  due  to  coxalgia.  In  hemiplegic 
contractures  the  upper  limb  may  be  drawn  in  to  the  trunk,  the  forearm 
is  flexed  at  a  right  angle,  the  thumb  is  bent  so  that  the  point  is  buried  in 
the  palm  of  the  hand,  and  it  is  covered  by  the  other  fingers. 

According  to  Strauss,1  extension  of  the  upper  limbs  is  quite  rare.  The 
lower  limb  is  extended,  so  that  the  foot  presents  the  appearance  of  talipes 
equiuus,  the  toes  having  a  claw-like  appearance.  The  thigh  is  extended 
on  the  jK'lvis,  and  the  whole  limb  is  adducted. 

Hysterical  contractures  of  a  permanent  character  may  affect  the  body, 

1  Trait6  <k-s  Affections  Vaporeuses. 
1  DCS  Coutractures,  Paris,  1875. 


HYSTERIA.  375 

either  laterally  or  below  the  waist,  or  but  one  member  may  be  involved. 
Charcot1  relates  a  case  in  which  the  left  leg  was  firmly  extended.  The 
foot  presented  the  deformity  of  talipes  varus,  and  the  limb  was  very  rigid, 
so  that,  by  lifting  it,  the  body  could  be  moved  without  bending  the  knee. 
The  contracture  could  be  overcome  by  chloroform,  but  returned  when  its 
effects  had  disappeared.  In  this  case  the  limb  was  agitated  by  a  tremor, 
or  "  tremulation  convulsive,"  as  this  author  calls  the  movement.  These 
hysterical  contractures  often  last  for  years,  and  are  cured  spontaneously. 
Skey2  relates  a  case  which  is  quite  interesting. 

"  In  the  year  18G4  a  young  lady  of  16  years  of  age  was  placed  under  my 
care  under  the  following  circumstances :  For  eight  months  prior  to  her 
visit  to  me,  she  has  been  suffering  from  inversion  of  the  left  foot,  which 
was  so  twisted  as  to  bring  the  point  of  the  foot  to  the  opposite  ankle  ;  in 
fact,  at  nearly  a  right  angle  with  the  foot  of  the  opposite  side.  Her  fam- 
ily consulted  a  surgeon  of  much  experience  in  the  treatment  of  distortion, 
and  of  orthopaedic  notoriety.  The  case  was  considered  as  an  example  of 
an  ordinary  distortion,  and  the  foot  was  placed  in  a  very  elaborately  made 
foot-splint,  by  the  force  of  which  it  was  made  to  approach  a  parallel  rela- 
tion to  the  opposite  side ;  but  it  was  an  approach  only,  for  no  mechanism 
could  retain  it  in  a  perfect  position,  the  toes  yet  to  some  degree  pointing 
inwards.  A  month  elapsed,  and  the  disease  continued  unchanged.  A 
second  orthopaedic  authority  was  then  consulted  in  conjunction  with  the 
first,  and  as  no  new  light  was  thrown  on  the  disease  by  the  combined 
opinions  of  the  two,  the  same  principle  of  treatment  was  recommended  to 
be  continued,  and  the  mechanism  was  yet  somewhat  more  elaborated,  and 
thus  the  eighth  month  of  the  young  lady's  life  passed  away,  during  which 
no  constitutional  treatment  was  resorted  to,  and  loss  of  exercise,  for  she 
walked,  it  was  almost  unnecessary  to  say,  with  great  difficulty." 

Skey  examined  the  foot,  and  arrived  at  the  conclusion  that  the  inversion 
was  too  great  to  be  due  to  the  muscles  alone,  and  discovered  that  those  of 
the  whole  limb  were  involved ;  that  the  disease  had  appeared  suddenly  in 
a  girl  of  15  years,  who  was  otherwise  well  and  strong,  and  in  whom  there- 
was  no  indication  of  acute  local  disease. 

The  apparatus  was  removed ;  a  hearty  diet,  with  tonics,  was  ordered ; 
she  was  told  to  walk ;  and  at  the  end  of  six  months  was  invited  to  a 
ball,  her  foot  being  still  deformed.  She  accepted  an  invitation  to  dance, 
and  remained  standing  throughout  the  entire  evening.  She  had  been 
suddenly  cured. 

Hemiplegia  and  paraplegia  of  an  hysterical  character  are  sometimes  met 
with,  as  well  as  local  paralysis,  but  the  face  is  rarely  affected  in  hysterical 
hemiparesis,  and  the  tongue  never  so. 

The  walk  is  quite  different  from  that  of  organic  hemiplegia,  and  accord- 
ing to  Todd  the  foot  is  simply  dragged  along  and  not  swung,  and  there  is 
an  absence  of  that  helplessness  which  is  so  characteristic  of  the  serious 
trouble.  Electric  sensibility  and  contractility  are  not  usually  affected, 
though  the  former  may  be  occasionally  impaired.  The  cure  is  spontane- 

1  Op.  cit.,  p.  307.  2  Hysteria,  etc.,  London,  1866. 


376  CEREBRO-SPINAL    DISEASES. 

ous,  and  there  is  never  atrophy  or  any  of  the  peculiar  tissue  changes  or 
neuritis  which  generally  follow  hemiplegia  from  cerebral  diseases.  Para- 
plegia  of  the  hysterical  variety  is  rarely  attended  by  any  urinary  or 
rectal  troubles,  and  never  by  incontinence,  and  the  muscles  are  well  nour- 
ished and  respond  to  electric  stimulation.  Some  voluntary  motion  is 
possible  in  the  recumbent  position,  and  it  is  only  when  the  patient  walks 
that  she  shows  her  loss  of  power.  Reynolds  states  that  a  peculiarity  of  the 
disease  is  the  fact  that  no  amount  of  help  can  keep  the  patient  from  stag- 
gering or  falling ;  she  may  be  supported  by  strong  arms,  but  she  sinks  to 
the  ground,  not,  however,  falling  entirely,  but  regaining  her  position  by  a 
voluntary  effort. 

The  visceral  troubles  are  a  host  in  themselves.  Not  only  may  the 
patient  complain  of  unbearable  pains  situated  in  the  liver,  stomach,  and 
other  organs,  but  there  may  be  urinary  affections  of  considerable  impor- 
tance. Two  varieties  of  hysterical  urinary  derangement  are  spoken  of  by 
Charcot,  one  being  ischuria,  and  the  other  a  complete  suppression,  which 
he  has  called  oligurie.  In  both  cases  the  urinary  passages  are  perfectly 
normal ;  in  the  first  there  is  simple  retention  of  urine  in  the  bladder ; 
and  for  a  long  time  (amounting  even  to  months  or  years)  it  will  be  found 
necessary  to  use  a  catheter. 

Laycock1  has  called  attention  to  this  state  of  affairs,  which  lasts 
sometimes  twenty-four  or  thirty-six  hours,  during  the  menstrual  epoch. 
Charcot  has  found  the  condition  to  last  even  longer — sometimes  for  several 
days.  This  suppression  of  urine  is  occasionally  accompanied  by  vomit- 
ing, and  the  presence  of  urea  has  actually  been  discovered  in  the  vomited 
substances.  This  has  been  explained  by  the  experiment  of  Brown- 
Sequard,  who  found  that  after  certain  forms  of  mutilation  carbonate  of 
ammonia  or  free  urea  was  found  in  the  intestines  of  animals,  which  settled 
the  fact  that  there  was  a  "  supplementary  elimination."  This  same  con- 
dition of  affairs  is  not  unusual  in  renal  disease,  and  the  odor  of  the 
breath  and  sweat  is  decidedly  uriniferous.  Vomiting  of  fecal  matter  is  a 
rare  symptom.  There  is  in  the  majority  of  cases  a  decided  increase 
in  the  amount  of  urine  voided.  It  is  of  a  very  light  color,  quite  limpid, 
and  of  low  specific  gravity,  and  is  sometimes  discharged  during  the  con- 
vulsive seixure.  Digestive  disturbances,  accompanied  by  eructations  of 
wind,  borborygmi,  epigastric  pain,  and  loss  of  appetite,  are  present  in 
most  cases. 

Abstinence  from  food  and  continued  unconsciousness  need  hardly  be 
alluded  to  in  this  chapter.  Cases  of  this  kind  derive  sensational  impor- 
tance from  newspaper  description,  and  from  their  very  hysterical  nature 
suggest  fraud  and  deception.  The  case  of  Louise  Lateau,  as  well  as 
others,  has  been  cleverly  investigated,  and  is  doubtless  familiar  to  my 
readers.  The  history  of  this  class  of  cases  furnishes  us  with  many  exam- 
ples, some  of  which  are  quite  ancient. 

1  Treatise  on  the  Nervous  Diseases  of  Women,  London,  1840,  p.  229. 


HYSTERIA.  377 

Senneratus1  writes  of  three  individuals  who  fasted  almost  two  years, 
and  ''yet,  though  lean,  were  in  good  health." 

Upon  the  authority  of  Schenck,2  we  are  informed  that  "Katherine 
Binder,  a  native  of  the  upper  Palatinate  in  Germany,  was  said  to  receive 
no  other  nourishment  than  air  for  more  than  nine  years.  John  Caffimer, 
in  the  year  of  our  Lord  1585,  commanded  her  to  be  watched  by  a  Minis- 
ter of  State  Ecclesiastic  and  two  Licentiates  in  Physic,  but  they  could 
make  no  discovery  of  her  being  an  impostor,  and  therefore  reported  it  to 
be  miraculous." 

A  symptom  which  I  am  inclined  to  think  very  common,  but  which  is 
not  generally  considered  so,  is  the  globus  hystericus.  The  patient  calls 
attention  to  a  "lump  which  rises  in  her  throat."  It  is  probably  nothing 
more  than  a  spasmodic  contraction  of  the  muscles  of  the  pharynx  or  oeso- 
phagus, or  in  other  cases  a  morbid,  sensory  disturbance.  It  "rises"  from 
the  epigastrium,  and  is  attended  by  dyspnoea  and  difficulty  in  deglutition. 
In  some  cases  obstinate  vomiting,  which  is  readily  excited  by  such  slight 
agencies  as  a  hand  laid  upon  the  surface  of  the  body,  or  the  administration 
of  a  very  small  amount  of  food,  is  a  formidable  symptom,  and  unless  cor- 
rected the  patient  may  become  speedily  exhausted.  In  one  case  which 
I  saw  at  the  request  of  Dr.  Austin  Flint,  this  condition  had  lasted  for 
several  years,  and  was  not  relieved  by  any  medication,  but  was  for  a 
time  stopped  by  pressure  made  over  the  left  ovary. 

The  disease  among  males  is  of  interest  because  of  its  rarity.  A  case 
presented  by  Bonnemaison,5  of  Toulouse,  may  be  cited: — 

The  patient  was  a  man  aged  72.  The  brother  of  the  patient  was  a 
hypochondriac;  and  his  mother,  who  died  at  the  age  of  81,  suffered  from 
various  forms  of  nervous  disturbance,  analogous  to  those  of  her  hysterical 
son,  after  reaching  her  7Gth  year.  The  attacks  in  the  case  of  Dr.  Bonne- 
maison's  patient  came  on  three  or  four  times  in  the  twenty -four  hours; 
ushered  in,  when  occurring  during  the  night,  by  nightmare;  when  in  the 
day,  by  various  sensations,  and  usually  by  pain  in  the  epigastric  region. 
An  aura  proceeding  from  this  point  travelled  along  the  sternum  to  the 
throat,  and  thence  to  the  mouth  and  tongue,  and  other  regions  of  the 
body,  the  muscles  of  the  parts  affected  by  this  sensation  being  thrown  into 
violent,  rapid,  and  unaccountable  convulsive  action.  The  patient  uttered 
strange  cries  and  yells,  or  repeated  the  same  words  over  and  over  again 
with  extreme  rapidity.  At  times  the  tongue  would  be  smacked  violently 
against  the  roof  of  the  mouth,  the  cheeks  spasmodically  puffed  out  with 
the  action  of  blowing  or  whistling,  and  the  jaws  snapped  violently  together, 
without,  however,  biting  the  tongue.  The  arms  were  moved  rhythmically 
together  with  the  action  of  flying,  or  drumming,  or  playing  the  piano. 
Sometimes  the  lower  limbs  shook  violently,  or  executed  the  movements 
of  dancing.  The  attacks  bore  a  strong  resemblance  to  those  of  the  "  con- 
vulsionnaires"  of  St.  Medard,  or  the  rhythmic  chorea  of  the  epidemics  of 
Louviers,  Toulouse,  and  Morziac.  The  disturbance  of  the  voluntary  mus- 

'  Prnx.  Med.,  p.  212.  2  Obs.  1.  3,  p.  306. 

3  Archives  GSnerales  do  M6d.,  Jan.  1875.     Abst.  in  Med.  News,  Oct.  1875. 


378  CEREBRO-SPINAL    DISEASES. 

cles  might  be  accompanied  by  spasm  of  the  involuntary  muscles  also,  or 
the  latter  might  form  the  chief  phenomena  of  the  paroxysm,  consisting  in 
hiccup,  eructations,  sighs,  and  borborygmi.  During  the  whole  of  the  at- 
tack the  hyperaesthesia  of  the  skin  was  excessive,  especially  at  the  fore- 
head, epigastric  region,  and  sternum ;  there  was  no  loss  of  consciousness. 
The  attack  ended  either  with  a  copious  flow  of  limpid  urine,  or  a  discharge 
of  tears.  There  was  never  any  pain  or  sensation  referable  to  the  genera- 
tive organs,  nor  anything  whatever  in  the  history  or  the  symptoms  indica- 
tive of  their  implication  in  any  way  whatever.  The  same  absence  of  any 
pathological  condition  of  the  organs  of  generation  has  been  observed  in 
cases  of  male  hysteria  observed  by  others. 

Causes. — Hysteria  is  most  decidedly  an  affection  of  women,  and  is 
connected  in  many  instances  with  some  sexual  or  uterine  derangement. 
Among  men  hysteria  is  far  less  rare,  I  think,  than  it  is  supposed  to  be, 
but  with  them  the  hysterical  trouble  is  of  a  lighter  grade,  and  it  is  unusual 
for  examples  either  of  anaesthesia,  convulsions,  or  contractures  to  be  wit- 
nessed. As  a  rule,  the  hysterical  man  possesses  a  smooth  face,  slender 
figure,  soft  falsetto  voice,  large  thyroid  cartilages,  small  hands,  and  taper- 
ing fingers,  and  sometimes  large  mammae.  His  genital  organs  are  poorly 
developed,  and  his  manners  are  mincing  and  effeminate.  Hysterical 
phenomena  are,  however,  not  uncommonly  presented  by  stalwart  men. 
Among  women  this  approach  to  the  appearance  and  behavior  of  the  other 
sex  is  inconsistent  with  the  development  of  hysteria.  Women  with  bushy 
eyebrows,  coarse  hair,  perhaps  a  slight  moustache,  angular  build,  narrow 
hips,  and  coarse  voices  are  seldom  hysterical.  They  are  "  strong-minded," 
rarely  emotional,  and  inclined  to  look  upon  the  hysterical  trouble  of  their 
weak  sisters  with  something  like  contempt. 

Reynolds  aptly  says :  "  Some  women  are  as  little  likely  to  become 
hysterical  as  some  men  are  to  fall  pregnant."  It  might  be  added  :  and  as 
their  chances  to  conceive  are  diminished.  Hysteria  is  of  much  more  com- 
mon appearance  among  spinsters  and  single  women,  and  is  far  from  being 
rare  among  old  maids  who  marry  late  in  life.  A  case  of  this  kind  fell 
under  my  observation  some  years  ago.  An  examination  revealed  an  un- 
developed  uterus;  and  from  the  nuptial  night  dated  a  series  of  nervous 
symptoms  of  a  grave  hysterical  character.  The  uterine  irritability  which 
is  connected  with  the  pregnant  state  between  the  ages  of  thirty  and  forty 
is  apt  to  produce  a  profound  impression  upon  the  nervous  system.  Among 
married  women  with  impotent  husbands,  or  among  those  who  have,  on  the 
other  hand,  suffered  through  the  lust,  inconsideration,  and  brutality  of 
husbands  of  another  kind,  the  disease  is  not  uncommon.  The  puerperal 
state,  lactation,  and  the  cessation  of  the  catamenia  favor  its  development. 

I  have  lately  treated  a  number  of  cases  of  a  class  which  I  am  sure  is 
familiar  to  most  medical  men,  especially  to  those  who  devote  the  greater 
part  of  their  time  to  the  study  of  nervous  disease.  I  allude  to  certain  ill- 
defined  hysterical  conditions  that  are  connected  with  or  follow  the  puer- 
jM-ral  state.  These  cases  do  not  come  under  the  head  of  puerperal  mania, 
M'hich  is  a  common  and  well-recognized  form  of  insanity,  but  are  difficult 


HYSTERIA.  379 

of  description  and  classification,  because  of  their  irregularity.  The 
patients  I  have  seen  have  all  been  uraemic  at  some  time  during  pregnancy, 
not  to  the  extent  which  is  accompanied  by  convulsions  or  other  grave 
symptoms,  but  the  blood-poisoning  was  much  more  extensive  than  it 
usually  is.  Barker  thinks  that  albuminuria  is  not  the  cause  of  puerperal 
mania,  but,  when  found,  is  merely  a  coincidence.  In  the  cases  I  allude 
to  it  was  always  present,  and  seemed  to  be  the  cause.  I  have  seen  the 
same  symptoms  expressed,  though  in.  a  less  marked  degree,  in  patients  who 
were  suffering  from  chronic  nephritis,  and  where  the  puerperal  state  had 
nothing  to  do  with  the  history.1 

In  the  spring  of  1875  Mrs.  C.  came  to  my  office  with  her  husband.  I 
found  her  to  be  an  amiable,  well-educated  woman  of  thirty-two  years  of 
age ;  her  manner  was  cheery  and  agreeable,  and  there  was  no  evidence  of 
mental  trouble.  Three  months  before  this  she  had  been  delivered  of  a 
child  at  full  term,  which  was  born  dead.  A  week  after  her  milk  "  dried 
up."  The  last  months  of  her  pregnancy  were  attended  by  evidences  of 
uraemia,  marked  anasarca,  clouded  urine  excreted  in  small  quantity,  but 
no  convulsions  or  mania.  Mrs.  C.'s  previous  history  was  uneventful. 
There  was  absolutely  no  hereditary  predisposition  to  insanity,  and  her 
mind  was  perfectly  clear  during  pregnancy. 

She  was  anaemic,  and  complained  of  dizziness,  palpitation,  gastric  dis- 
turbance, vertical  headache,  loss  of  memory,  ringing  in  the  ears,  etc.  She 
passed  her  urine  at  the  time  of  her  visit  in  normal  amounts,  and  it  did  not 
contain  albumen.  Her  complexion  was  pale,  and  her  pupils  were  dilated. 
A  very  slight  blueness  of  the  skin  was  apparent,  but  was  confined  to  the 
hands.  The  lips  had  not  lost  their  lines  of  expression,  which  is  generally 
the  case  in  melancholia,  and  they  were  not  swollen.  She  was  inclined  to 
sleep.  Considering  that  the  symptoms  indicated  "  cerebral  anaemia,"  I 
began  with  iron,  phosphorus,  and  other  remedies  of  the  same  kind. 

Two  days  after  this  visit  she  again  appeared  at  my  office,  looking  much 
agitated,  and  saying  that  she  had  come  for  "protection  from  herself." 
She  had  been  tempted  to  get  up  from  her  bed  and  cut  her  throat  with  her 
husband's  razors.  She  was  perfectly  cognizant  of  her  condition,  and  was 
aware  of  the  fearful  nature  of  the  act  she  was  tempted  to  perform.  After 
a  talk  of  half  an  hour,  she  left  me,  feeling  settled,  and  without  the  desire. 
On  another  occasion  she  came  to  see  me,  as  "  she  had  the  feeling  again." 
She  had  taken  her  sister's  baby  in  her  lap,  and  while  it  was  there  she 
"  suddenly  felt  like  throwing  it  on  the  floor"  witli  all  her  force.  At 
another  time  she  was  prompted  to  run  the  blade  of  a  pair  of  scissors  into 
the  fontanelle.  These  impulses  would  recur  every  week  or  so,  when  she 
always  came  to  see  me,  and  would  sit  a  few  minutes,  talk  upon  other  sub- 
jects, and  rise  to  go,  saying :  "  Now,  doctor,  the  feeling  has  passed  off." 
Not  at  this  time,  nor  at  any  other,  were  there  delusions  of  any  kind. 
Under  treatment  she  improved  in  general  health,  and  h«r  nervous  symp- 
toms disappeared. 

•  Her  last  morbid  impulse  occurred  during  the  fourth  month  after  treat- 
ment. One  evening,  with  her  husband  and  brother,  she  went  upon  the 
house-top  to  see  a  fire.  While  there  the  old  feeling  returned,  and  she 

1  Boston  Med.  and  Surg.  Journ.,  June  15,  1876. 


380  CEREBRO-8PINAL    DISEASES. 

would  have  thrown  herself  from  the  roof,  had  she  not  been  prevented.  This 
wns  the  last  and  most  serious  expression  of  the  disease.  Since  that  time 
she  has  not  had  a  return,  and  says  she  is  perfectly  well. 

A  second  case  I  lately  saw  was  attended  by  slight  though  perfectly  de- 
fined mental  changes.  The  patient  was  a  young  married  woman  of 
twenty-four  years.  For  some  time  before  parturition  and  during  her 
pregnancy  there  was  kidney  trouble.  Before  her  labor  she  was  a  loving 
and  devoted  wife,  but  shortly  after  lost  all  of  her  amiability,  and  treated 
her  husband  and  mother  with  marked  coolness,  and  sometimes  with  <!<•- 
cided  rudeness.  A  month  after  delivery  she  took  a  deep  interest  in 
religious  matters,  and  carried  the  observance  of  her  religious  duties  to 
such  a  pass  as  to  be  disagreeable  to  all  about  her.  She  did  eccentric 
things,  such  as  getting  up  at  night,  going  down  to  the  piano  in  the  draw- 
ing-room, and  singing  hymns.  When  reminded  of  the  unseasonableness 
of  the  hour,  she  would  return  to  her  bed,  first  shutting  the  hymn-book  in 
a  mechanical  manner. 

I  saw  her  in  this  condition,  and  found  a  state  closely  bordering  on 
melancholia,  though  there  was  no  mental  depression,  no  anxious  facies, 
no  sighing,  no  hopelessness.  A  persistent  use  of  agents  which  would 
restore  the  action  of  the  kidneys,  combined  with  fresh  air  and  a  well-regu- 
lated diet,  did  her  much  good.  After  a  few  weeks  the  patient  slept  well, 
and  the  mental  irritability  gradually  disappeared. 

In  both  of  these  cases  there  were  symptoms  which  were  not  those  of 
insanity.  In  Case  I.  the  patient  was  able  to  reason,  and  had  full  con- 
sciousness of  her  infirmity ;  so  that  she  had  the  power  to  seek  the  society 
of  others  when  she  felt  the  impulse.  There  was  the  absence  of  all  physi- 
cal signs  of  insanity,  except  the  coloration  of  the  skin.  In  the  second 
case,  the  short  duration  of  the  mental  trouble,  and  its  subsidence  with 
improvement  of  the  kidney  difficulty,  proved  it  to  be  a  functional  de- 
rangement. 

As  regards  age,  hysteria  rarely  begins  before  the  twelfth  year ;  it  generally 
takes  its  origin  at  the  time  of  puberty,  and  from  this  period  may  continue 
through  life.  It  not  rarely  begins  after  marriage,  or  sometimes  not  until 
after  the  menopause,  but  this  is  exceptional.  In  males  it  begins  in  middle 
life,  though  I  have  seen  the  affection  among  boys.  Hysteria  is  not,  neces- 
sarily a  disease  of  the  well-to-do,  though  indolent  habits  and  luxurious 
living  favor  its  development  ;  but  it  frequently  appears  among  overworked 
shop-girls  who  are  compelled  to  stand  for  many  hours  during  the  day. 
The  follies  of  fashionable  life  have  much  to  do  with  the  production  of  a 
morbid  performance  of  functions  of  the  nervous  system.  Continued  rounds 
of  dissipation,  parties  and  balls  which  do  away  with  sleep,  together  with 
excitement  and  late  suppers,  days  of  idleness  spent  in  reading  French 
novels  and  eating  improper  food,  or  tippling  liqueurs,  especially  favor  the 
development  of  this  morbid  state.  This  mode  of  life,  when  kept  up  for 
some  time,  especially  when  the  menstrual  periods  are  disregarded,  brings 
about  a  condition  of  erethism  which  expresses  itself  in  the  symptoms  I 
have  named.  Dysmenorrhcca  may  be  attended  by  attacks  of  this  kind, 
and  so  may  menorrhagia,  but  many  cases  occur  even  when  there  is  no  dis- 


HYSTERIA.  381 

turbance  of  menstrual  function.  Abnormalities  of  the  position  of  the 
uterus,  and  excessive  sexual  excitement,  whether  from  masturbation  or 
coition,  have  decided  etiological  bearing,  while  warm  weather  favors  the 
development  of  attacks.  Mental  worry,  emotional  excitement,  an  attack 
of  illness,  and  a  number  of  influences  of  the  same  kind  all  act  as  exciting 
causes. 

Morbid  Anatomy  and  Pathology — Accidental  lesions  are  some- 
times found,  but  so  irregular  is  their  character  that  they  are  valueless  as 
indications. 

As  to  the  pathology  of  the  affection,  very  little  can  be  said  in  addition 
to  what  has  already  been  stated  in  speaking  of  the  symptoms.  Hysteria 
may  be  said  to  be  a  very  near  relation  to  insanity.  Hammond  even  con- 
siders it  a  form  of  insanity  ;  but  I  should  be  loath  to  believe  that  so  many 
people  are  actually  insane.'^  Hysteria  is  rather  a  mental  incoordination. 
Emotional  exaltation,  connected  with  liveliness  of  ideation  and  with  feeble 
volition,  and  a  paralysis  of  judgment,  may  be  said  to  be  the  mental  condi- 
tion of  an  hysterical  patient.  The  balance  is  lost ;  and  when  the  emotional 
side  has  full  play,  all  the  reflex  and  sensational  functions  are  active  and 
unchecked,  while  it  is  only  with  difficulty  that  the  governing  side  to  which 
belong  volitional  and  intellectual  control  is  made  to  counteract  the  other. 
This  is  only  brought  about  by  the  most  powerful  agencies,  and  sometimes 
these  are  inefficient.  If  the  reader  will  consult  an  article  by  Lauder 
Brunton,1  in  one  of  the  West  Riding  Reports,  he  will  find  some  excellent 
diagrams  which  illustrate  the  mechanism  of  the  nervous  centres  in  the 
physiology  of  inhibition. 

I  have  slightly  modified  the  chart  of  this  author  by  introducing  another 
centre.  Let  Fig.  46  represent  the  arrangement  of  nerve  centres  concerned 
in  the  performance  of  the  functions  of  the  cerebro-spinal  system.  I  indi- 
cates the  centre  of  ideation,  E  an  emotional  centre,  W  a  will  centre,  M 
a  motor  centre  innervating ;  M  (a  muscle),  v  (a  vessel),  and  G  (a  gland). 
S  is  a  sensory  centre,  and  P  the  origin  of  an  external  impression.  The 
connecting  lines  are  efferent  and  afferent  nerves.  It  will  be  seen  that  I  is 
in  centrifugal  communication  with  W,  with  M,  S,  and  with  E.  So  that 
ideas  which  are  evolved  without  external  stimulus  may  find  motor  expres- 
sion either  in  a  voluntary  or  involuntary  manner ;  may  affect  the  emo- 
tional centre,  or  may  be  stimulated  by  impressions  received  either  from 
that  centre  or  from  S.  External  impressions  may  be  transmitted  from  P 
either  to  S,  to  E,  or  to  M ;  in  one  case  being  perceived  and  transmitted 
to  a  higher  centre,  or  being  converted  into  a  reflex  action.  E  is  affected 
by  S  and  by  I,  and  in  turn  influences  M  and  I,  and  to  a  slight  degree  W; 
or  on  the  other  hand  may  be  controlled  by  W.  In  the  normal  state  we 
may  roughly  suppose  the  proportions  of  these  areas  to  be  represented  in 
the  right-hand  diagram.  In  the  hysterical  state  their  relative  (left-hand 
diagram)  size  is  greatly  altered ;  E  gains  in  size,  and  W  is  very  much 

1  West  Riding  Lunatic  Asylum  Reports,  vol.  iv.  p.  179. 


382 


CEREBRO-SPINAL    DISEASES. 


diminished.  The  relative  size  of  the  communicating  tracts  also  undi-r- 
goes  modification.  Though  this  explanation  is  decidedly  rough  and  super- 
ficial, I  trust  it  will  give  the  reader  a  better  idea  of  the  pathology  of  this 
affection  than  would  any  extended  written  description. 

Fig.  46. 


The  Pathology  of  Hysteria. 

Diagnosis. — As  hysteria  may  counterfeit  nearly  every  known  symp- 
tom, it  will  be  seen  that  the  task  of  making  a  diagnosis  is  not  always  an 
easy  matter.  If,  however,  we  consider  that  the  symptoms  are  generally 
presented  in  a  group,  which  is  decidedly  irregular  and  inharmonious,  and 
that  the  patient  is  on  the  alert  in  regard  to  all  that  goes  on  about  her ; 
that  she  has  a  fear  of  severe  treatment ;  that  the  use  of  chloroform  will 
certainly  overcome  the  contractures;  and  that  the  cure  is  generally  sudden, 
there  is  not  much  chance  for  mistake.  Besides,  there  is  never  any  evidence 
of  gross  organic  change,  the  muscles  only  losing  their  fulness  from  inaction. 

Prognosis — If  the  individual  has  suffered  for  a  great  length  of  time, 
and  especially  if  there  be  confirmed  uterine  disease,  the  chances  of  entire 
recovery  will  be  extremely  bad.  The  disease  is  not  only  discouraging 
in  the  way  of  treatment,  but  annoying  to  the  friends,  and  far  more  disa- 
greeable; to  the  physician,  who  receives  very  little  for  his  pains  but  abuse 
and  want  of  appreciation.  Some  cases  may  be  easily  cured,  and  these 
are  among  young  people.  Much,  however,  depends  upon  treatment. 

Treatment — The  history  of  the  treatment  of  hysteria  is  curious  in 
the  extreme.  Going  back  to  the  middle  ages  we  find  numerous  examples 
of  miraculous  cures,  which  were  undoubtedly  of  an  hysterical  character. 
Schele  de  Vere,  in  his  little  work  entitled  "  Modern  Magic,"  thus  speaks 
of  a  favorite  mode  of  treatment  which  has  been  followed  by  the  Zouave 
Jacob  and  many  others  in  modern  times  : — 


HYSTERIA.  383 

"  The  imposition  of  hands  for  the  purpose  of  performing  miraculous 
cures  has  been  practised  from  time  immemorial ;  Chaldees  and  Brahmins 
alike  using  it  in  cases  of  malignant  disease.  The  kings  of  England  and 
of  France,  and  even  the  counts  of  Hapsburg  in  Germany,  have  been 
reputed  to  be  able  to  cure  goitres  by  the  touch  of  their  hands.  The  idea 
seems  to  have  originated  in  the  high  North,  King  Olave  the  Saint  being 
reported  by  Snorre  Sturleson  as  having  performed  the  ceremony.  From 
thence,  no  doubt,  it  was  carried  to  England,  where  the  Confessor  seems 
to  have  been  the  first  to  cure  goitres." 

"In  more  recent  times  a  prince,  Hohenlohe,  in  Germany,  claimed  to  have 
performed  many  miraculous  cures,  beginning  with  Princess  Schwarzen- 
berg,  whom  he  commanded  in  the  name  of  Christ  to  be  well  again.  Many 
ot  his  patients,  however,  were  only  cured  for  the  moment.  When  their 
faith,  excited  to  the  utmost,  cooled  down  again,  their  infirmities  returned. 
Still  there  remain  facts  enough  in  his  life  to  establish  the  marvellous 
power  of  his  strong  will,  when  brought  to  bear  upon  peculiarly  receptive 
imaginations  and  aided  by  earnest  prayer." 

Several  years  ago  an  individual  named  Newton  went  about  the  country. 
It  was  his  custom  to  hire  a  large  hall  and  extensively  advertise.  Upon 
the  day  appointed  he  would  meet  the  lame,  halt,  and  blind,  and  after 
powerful  exhortations  and  prayers,  tell  them  to  form  in  line  and  pass  one 
by  one  before  him.  The  emotional  excitement  and  eager  anticipation 
were  sufficient  in  some  instances  to  divert  the  hysterical  patients  who 
chanced  to  be  among  the  number,  so  that  in  many  instances  there  were 
spontaneous  cures,  the  lame  dropping  their  crutches,  and  starting  off  at  a 
lively  gait,  and  the  blind  recovering  their  sight. 

Dr.  G.  M.  Beard,  in  an  entertaining  paper  upon  "  Mental  Therapeu- 
tics," recently  called  attention  to  some  experiments  he  had  been  making. 
In  many  instances  of  functional  disease,  he  assured  the  patients  that  their 
recovery  would  take  place  in  some  very  short  time,  and  found  that  at  the 
time  specified  they  returned  completely  cured.  This  procedure  in  cases 
of  hysteria  is  of  great  value.  I  have  repeatedly  stopped  an  hysterical 
attack  by  a  douche  of  cold  water  or  by  the  exhibition  of  the  cautery. 
Oftentimes,  after  the  patient  has  been  pleaded  with,  threatened,  and  dosed 
to  no  effect,  a  sudden  fright  or  a  sharp  word  or  two  will  do  more  for  her 
than  anything  else ;  but  the  physician's  demeanor  to  his  patient  should 
always  be  characterized  by  firmness  and  dignity,  and  not  by  harshness  or 
undue  severity. 

As  to  medication,  we  may  make  use  of  the  motor-depressants,  bromide 
of  sodium,  hyoscyamus,  or  the  mono-bromide  of  camphor,  in  doses  of  three 
grains  every  hour,  till  quiet  is  obtained;  the  spts.  etheris  co.,  chloroform 
or  chloral,  and  valerian,  or  its  compound,  valerianate  of  zinc  (FF.  3,  4, 
23,  38,  53,  54,  55,  87).  The  obstinate  vomiting  is  occasionally  stopped 
by  hypodermic  injections  of  morphine ;  and  a  belladonna  plaster  over  the 
irritable  ovary  will  often  prove  to  be  an  excellent  form  of  treatment. 

For  the  anaesthesia  and  paralysis,  strychnia  and  electricity  are  the  best 


384  CEREBRO-8PINAL    DISEASES. 

remedies  which  I  know  of,  the  latter  being  employed  in  its  induced  form, 
and  the  electric  brush  applied  upon  a  dry  surface.  General  treatment  of 
a  tonic  character  should  be  used  when  it  is  possible;  and  iron,  in  combina- 
tion with  phosphorus  or  phosphoric  acid,  cod-liver  oil,  and  sea-baths 
(FF.  8,  9,  10,  12,  24,  57,  32),  together  with  local  treatment.  Local  dis- 
ease should  be  promptly  eradicated  if  possible,  uterine  versions  or  flexions 
righted,  and  the  menstrual  function  restored  to  its  regular  character. 
In  those  bed-ridden  cases  which  are  so  discouraging  and  trying,  we  may 
use  Weir  Mitchell's  treatment.  A  patient  may  lie  in  bed  leading  a  very 
irregular  life,  and  doing  just  about  what  she  chooses,  without  improving 
in  the  least;  while,  if  her  room  be  darkened,  her  diet  changed,  and  her 
muscular  tone  kept  up,  a  cure  may  be  often  wrought. 


HYSTERO-EPILEPSY. 

This  interesting  variety  of  hysterical  trouble  has  received  a  great  deal 
of  attention  from  Charcot,1  Dunant,*  Dubois,  and  Bourneville,  as  well  as 
from  many  other  writers,  some  of  whom  did  not  recognize  its  distinct 
character  until  after  Charcot's  valuable  investigations  had  been  announced. 

Tissot8  says  that  "  the  hysterical  attack  sometimes  resembles  epilepsy, 
so  much  so  as  to  have  received  the  name  epileptiform  hysteria,  but  the 
attack  nevertheless  does  not  possess  the  true  character  of  epilepsy." 

Others,  among  whom  are  Briquet,4  Landouzy,  and  Saunders,  have  also 
described  the  condition. 

Upon  the  authority  of  Charcot,5  the  combinations  of  epilepsy  and  hys- 
teria take  place  under  the  following  different  circumstances : — 

1.  «.    Epilejisy  being  the  primary  disease,  upon  which  hysteria  is  en- 
grafted, under  the  influence  of  emotional  causes  or  at  the  time  of  puberty. 

b.  After  marriage  (vide  Landouzy 's  Case),  the  epilepsy  having  always 
existed.  After  connection,  the  hysterical  feature  of  the  attack  is  developed. 
In  this  case  the  hysterical  character  of  the  epilepsy  subsided  when  sexual 
excitement  was  interrupted  by  pregnancy. 

2.  The  hysteria  being  primary,  the  epilepsy  is  added  thereto.     A  rare 
condition. 

3.  Convulsive  hysteria  coexisting  with  petit-mal. 

4.  An  epileptic  attack,  followed  by  hysterical  contractures,  anaesthesia, 
etc. 

I  have  observed  a  form  which  slightly  differs  from  any  of  the  above. 
The  patient,  an  epileptic,  was  seized  occasionally  with  hystero-epileptic 
attacks  during  the  menstrual  periods,  and  at  other  times  there  was  un- 
complicated epilepsy.  She  has  had  epilepsy  since  the  fifth  year,  when 
she  was  frightened  by  her  mother,  who  threatened  to  beat  her. 

1  LcQons  surles  Maladies  du  Systfeme  Xerveux,  part  i.,  Paris,  1872. 

2  De  rHyst6ro-6pilepsie.  3  Maladies  des  Xerfs,  quoted  by  Charcot. 
4  Op.  cit.  *  Op.  cit.,  p.  324. 


HYSTERO-EPILEPSY.  385 

Symptoms — I  may  illustrate  the  course  of  the  affection  by  the  rela- 
tion of  two  personal  cases : — 

CASE  I — A.  P.,  let.  18,  since  the  beginning  of  the  menstrual  epoch, 
has  suffered  from  her  present  form  of  hystero-epileptic  attacks,  which 
have  come  on  generally  just  after  the  cessation  of  the  catamenial  period. 
She  has  been  very  irregular,  and  has  suffered  from  amenorrhcea,  but  there 
is  no  uterine  disease  that  I  can  discover.  This  amenorrhoea  lias  amounted 
to  an  entire  cessation  of  the  menstrual  flow  for  several  months  at  a  time, 
during  which  she  would  have  her  attacks.  Some  of  these  attacks  were 
like  that  I  shall  presently  describe,  and  lasted  for  several  days.  There 
was  no  succession  of  attacks,  but  usually  several  severe  but  distinct  epi- 
leptic seizures,  and  afterwards  an  hystero-epileptiform  paroxysm.  She 
had  been  in  the  Epileptic  Hospital  for  some  time,  and  had  given  a  great 
deal  of  trouble  by  her  irritability  and  mischief-making  propensities.  Her 
attacks  at  the  hospital  were  three  in  number  during  one  year,  each  of 
them  lasting  from  two  to  three  days  at  a  time,  during  which  there  were 
suppression  of  urine,  vomiting,  and  hemianaesthesia,  which  in  one  instance 
was  on  the  right  and  twice  on  the  left  side. 

Her  most  pronounced  attack  occurred  while  she  was  staying  at  her 
mother's  house,  where  I  was  summoned  to  see  her.  This  was  on  the  14th 
of  March,  1877,  when  her  mother  came  to  my  office,  and  told  me  that  her 
daughter  had  been  ill  since  the  preceding  Thursday ;  that  she  had  gone 
with  her  sister  to  see  a  friend ;  and  that  while  there  she  had  been  seized 
with  a  severe  fit,  and  could  not  go  home  until  the  next  day  (March  9). 
She  said  that  on  her  return  her  daughter  complained  of  headache,  pain  in 
the  back,  over  the  ovaries,  and  abdominal  discomfort,  and  as  the  time  for 
her  menses  had  come,  she  gave  her  a  pill  of  aloes  and  myrrh  on  Saturday, 
and  another  on  Sunday  night,  with  no  result,  and  a  warm  hip-bath  on 
Monday.  (She  had  not  menstruated  since  December,  1876.)  On  Mon- 
day she  had  several  severe  epileptic  fits,  with  frothing  at  the  mouth,  during 
which  she  bit  her  tongue,  and  went  to  bed,  where  she  remained  until  I  saw 
her.  I  went  to  the  house,  and  found  that  she  had  been  seemingly  uncon- 
scious since  Monday  night,  that  she  had  been  "frothing  at  the  mouth" 
since  that  time,  and  that  on  Tuesday  she  began  to  mutter  and  talk  to  her- 
self; that  she  had  had  hallucinations  and  delusions,  some  of  them  of  a 
painful  character,  believing  that  she  had  been  followed  by  a  nurse  from 
the  hospital,  whose  intention  was  to  kill  her.  When  her  mother  entered 
the  room,  she  berated  her  soundly,  and  was  quite  abusive,  indulging  in 
obscene  language. 

I  found  her  lying  upon  the  bed,  lightly  covered  by  a  sheet.  The  muscles 
of  her  back  were  rigidly  contracted,  so  that  her  position  was  one  of  opis- 
thotonos ;  her  head  was  turned  to  one  side,  and  her  tongue  was  protruded. 
Her  eyes  were  open,  and  the  pupils  widely  dilated,  and  insensible  to  light.- 
Her  expression  was  blank,  and  she  was  apparently  unmindful  of  her  sur- 
roundings. Her  arms  were  drawn  over  her  chest,  and  her  forearms 
slightly  flexed  and  crossing  each  other.  Her  thumbs  were  bent  in,  and 
covered  by  her  other  fingers,  which  were  rigidly  flexed.  Her  pulse  was 
124  ;  temperature  101.2°  ;  respiration  35.  She  was  muttering  to  herself  a 
disconnected  string  of  words  without  any  meaning,  and  continued  them 
during  my  visit.  She  had  not  eaten  for  twenty-four  hours,  and  I  ordered 
milk  and  chloral  hydrate  in  twenty-grain  doses,  to  be  forced  into  her 
mouth  if  she  did  not  open  it  of  her  own  accord. 
25 


386 


CEREBRO-SPINAL    DISEASES. 


On  my  return  the  next  morning,  the  mother  told  me  that  she  had  hud 
delusions  during  the  night,  and  had  cursed  those  of  her  family  who  ven- 
tured to  approach  her.  I  found  that  the  rigidity  of  the  previous  day  had 
become  less  marked,  but  that  her  right  hand  and  forearm  were  beneath  t  In- 
lower  part  of  her  back.  The  right  corner  of  her  mouth  was  drawn  down- 
wards, and  her  eyes  were  still  open,  and  the  corneas  anaesthetic.  Sin-  did 
not  know  me.  Temperature  100°  ;  pulse  108 ;  respiration  28.  On  the 
following  morning  Dr.  Charles  E.  Lockwood  of  this  city  went  with  me  to 
see  her.  She  was  then  much  better,  and  was  less  rigid,  but  the  right 
hand  was  tightly  clinched,  and  no  persuasion  would  induce  her  to  open  it. 
Her  toes  were  also  flexed,  and  her  right  foot  presented  the  appearance 
called  by  Charcot,  "  le  pied  bot  hyste'rique."  Her  corneae  were  sensitive, 

Fig.  47. 


Hystero-Epilepsy. 

and  her  pupils  less  dilated.  There  was  some  rolling  of  the  eyeballs  from 
side  to  side,  and  the  patient  occasionally  sighed.  Her  pulse  was  now  only 
9G,  and  was  small  and  irritable  ;  the  temperature  was  99°.  When  sharply 
spoken  to,  she  said  "  Doctor,"  and  relapsed  into  a  state  of  stupidity,  turn- 
ing her  head  from  right  to  left,  and  staring  at  the  ceiling.  She  occasion- 
ally moved  her  tongue,  as  if  her  mouth  was  dry.  Dr.  Lockwood  suggested 
the  experiment  of  frightening  her,  and  so  we  threatened  the  use  of  the 
cautery,  the  mention  of  which  first  brought  forth  remonstrance  and  after- 
wards a  reply  to  our  questions. 

Her  mother  stated  that  she  had  not  passed  urine  for  several  days.  I 
did  not  find  a  distended  bladder,  but  when  the  catheter  was  introduced,  it 
brought  away  about  half  a  pint  of  light-colored  urine.  This  suppression  of 
urine  continued  for  several  days.1  She  arose  from  her  bed  the  day  after 
this  last  visit,  and  her  menses  appeared.  During  the  next  three  or  four 
days  there  was  slight  hemianaisthesia  of  the  right  side. 

CASE  II — A  young  lady,  19  years  old,  had  been  my  patient  for  nearly 
u  year,  during  which  she  had  had  on  an  average  about  one  attack  of  haut- 
mat  in  a  week.  Her  epilepsy  dated  from  the  ninth  year,  and  was  not  de- 
pendent upon  any  discoverable  cause.  At  all  times  she  is  irritable,  pettish, 
and  techy,  and  leads  a  very  irregular  life.  There  was  nothing  remarka- 
ble about  her  attacks  ;  they  were  not  very  violent,  nor  were  they  connected 


'  It  is  probable  that  this  urinary  derangement  was  of  the  form  called  by  Char- 
cot  oliguria. 


HYSTERO-EP1LEPSY.  387 

with  any  hysterical  manifestation.  There  was  rarely  any  coma  ;  but  the 
attacks  were  more  severe  about  the  time  of  the  menstrual  discharge,  which 
was  never  abundant.  On  September  12,  1876,  I  was  telegraphed  for 
to  see  the  patient.  The  day  before  my  arrival,  without  any  premonitions, 
she  had  had  an  attack  very  much  like  all  the  others,  but  instead  of  falling 
asleep  she  remained  convulsed,  and  apparently  unconscious.  She  vomited 
two  or  three  times,  and  became  quite  cyanotic;  so  the  local  physician  was 
sent  for.  He  found  it  impossible  at  first  to  open  her  mouth  to  remove  the 
substance  which  had  collected  therein  and  distended  the  cheeks,  and  it 
was  only  when  he  was  assisted  by  others  that  he  could  do  so.  She  was 
placed  in  bed,  and  remained  in  this  state,  the  eyeballs  rolling  from  side  to 
side,  the  body  drawn  slightly  to  the  right  side,  and  the  hands  clinched. 
She  became  delirious  during  the  night,  and  had  delusions  of  a  lively  kind, 
like  those  of  a  patient  with  delirium  tremens.  Outbursts  of  hysterical 
laughter  and  jactitations  of  the  limbs  followed  in  the  morning,  and  then 
she  became  quiet,  but  the  muscles  were  somewhat  rigid.  I  arrived  at 
about  2  P.M.,  and  found  her  lying  upon  the  bed  with  open  eyes  and 
meaningless  stare.  Her  right  arm  was  rigidly  adducted,  and  the  bed- 
clothes were  tightly  grasped  in  her  hand.  The  head  was  drawn  so  that 
the  chin  was  approximated  somewhat  to  the  chest.  The  teeth  were  set 
together,  and  there  was  some  grinding  of  the  molars.  She  breathed 
noisily,  there  being  an  accumulation  of  mucus  in  the  throat.  Temperature 
100.2°  ;  pulse  86.  The  pupils  were  dilated,  and  seemingly  unaffected  by 
light.  Pressure  upon  the  right  ovary  caused  her  to  shrink  somewhat.  Her 
abdomen  was  distended  by  flatus.  During  the  night  she  became  somewhat 
relaxed,  and  muttered  unintelligibly,  but  in  a  petulant  tone.  She  fell  into 
an  apparent  sleep  about  5  A.  M.,  her  respiration  being  natural.  She  awoke 
at  about  5  P.  M.  of  the  same  day  (the  third),  and  though  somewhat  fa- 
tigued, arose  and  went  about.  She  was  not  hemianaesthetic,  but  ischuria 
lasted  for  several  days. 

An  inspection  of  the  cases  of  Charcot  and  others  will  enable  the  reader 
to  detect  certain  symptoms  which  are  alike  in  all  the  patients. 

CASE  III Reported  by  Charcot.  Marc ,  23.  Hystero-epilepsy 

dated  from  the  1 6th  year  ;  attended  by  hemianzesthesia  and  hemiparesis 
of  left  side.  Daltonism  of  left  eye  ;  frequent  vomiting.  Attack  preceded 
by  an  aura  and  pain  in  left  ovary.  Attacks  included  three  stages  :  a. 
Tetaniform  contraction,  epileptiform  convulsions,  b.  Violent  movement 
of  trunk  and  lower  extremities  (period  of  contortion).  Silly  and  discon- 
nected talking.  Patient  appeared  to  be  semi-delirious,  c.  Laughing  fits ; 
attacks  stopped  by  ovarian  compression. 

CASE  IV Charcot.  Cot.,  21  years.  Hysteria  dated  from  the  15th 

year,  and  followed  cruel  treatment  at  the  hands  of  her  father,  when  she 
took  to  drink  and  became  a  prostitute.  Local  symptoms  are  :  right  hemi- 
ansesthesia,  ovarian  pain,  permanent,  and  tremulation  of  the  right  lower  ex- 
tremity. Convulsions  followed  ovarian  pain  ;  they  are  tonic,  and  she  bit 
her  tongue  and  frothed  at  the  mouth.  The  second  period  followed  at 
once,  and  was  marked.  The  attack  often  terminated  by  movements  of 
the  pelvis,  laryngeal  constriction,  crying  attack,  passage  of  large  quantities 
of  urine.  Ovarian  pressure  moderated  attack,  but  did  not  arrest  it. 

CASE  V Charcot.  Legr.  Ge'nevieve,  28.  Hysteria  dated  from 

puberty.  Permanent  local  symptom  ;  left  hemiantesthesia,  ovarian  pain, 
and  mental  peculiarities  (bizarre).  Aura  quite  marked,  and  so  are  cardiac 


388  CEREBRO-SPINAL    DISEASES. 

palpitation  and  head  symptoms  ;  attack  may  be  divided  into  three 
a.  Epileptiibrm  convulsion,  frothing  at  the  mouth,  and  stertor.  b.  Move- 
ment of  limbs  and  body.  c.  Period  of  delirium,  during  which  she  detailed 
the  events  of  her  life.  Occasionally  last  stage  would  be  characterized  by 
hallucinations,  when  she  would  see  crows,  serpents,  etc.  She  would  at 
other  times  dance.  Ovarian  pressure  arrested  attack. 

CASE  VI Charcot.      Ler.,  48  years.      Attacks  date  from  early  life, 

when  she  was  frightened  by  a  dog,  and  by  the  sight  of  the  body  of  a  wonuui 
who  had  been  assassinated.  Local  symptoms  :  hemianoesthesia  of  ovary  ; 
paresis  and  contractures  of  the  upper  and  lower  right  extremities,  and 
occasionally  the  left.  Attacks  begin  by  ovarian  aura,  followed  by  epilep- 
tiform  and  tetaniform  convulsions,  after  which  she  assumed  the  most  try- 
ing postures.  At  the  time  of  the  attack  she  falls  into  a  delirium,  during 
which  she  indulges  in  furious  invectives,  cryirig  to  imaginary  persons : 
"  Villains,  robbers,  brigands  !  fire,  fire  !  Oh  the  dogs  !  oh,  I'm  bitten!" 
these  being  suggested  by  memories  of  her  childish  fears.  When  the  con- 
vulsive part  of  the  attack  is  terminated,  there  follow  :  1.  Hallucination  of 
sight,  the  patient  seeing  skeletons,  frightful  animals,  spectres,  etc.;  2.  A 
paralysis  of  the  bladder ;  3.  A  paralysis  of  the  pharynx ;  4.  Finally,  a 
more  or  less  permanent  contracture  of  the  tongue.  These  last  symptoms 
remain  for  several  days,  during  which  it  is  necessary  to  feed  the  patient 
with  the  stomach-pump,  and  then  draw  off  her  urine. 

Two  cases,  reported  some  years  ago,1  resemble  the  more  modern  hys- 
tero-epilepsy  so  closely  that  I  am  inclined  to  infer  that  they  were  attacks 
of  this  disease. 

CASE  VII — Arguinosa's  Case.  Woman,  twenty  years.  Epileptiform 
convulsions  h'rst  showed  themselves  during  infancy,  in  consequence  of  head 
injury.  They  reappeared  at  puberty.  While  residing  in  the  house  of  Dr. 
Arguinosa  she  complained  of  ovarian  pains.  The  precursory  signs  of  an 
epileptic  attack  soon  showed  themselves,  and,  on  returning  from  a  walk, 
"  she  had  scarcely  time  to  throw  herself  on  a  bed  before  she  lost  both  sen- 
sation and  motion.  The  skin  was  hot,  respiration  loud,  pupil  immovable, 
eyelids  closed  convulsively,  limbs  flexible,  while  the  lips  were  convulsively 
moved,  or  else  a  sardonic  smile  sat  upon  them.  Bleeding  was  about  to  be 
practised,  when,  all  of  a  sudden,  after  some  horripilations,  the  skin  became 
cold  and  colorless,  the  pulse  and  respiration  were  suspended,  and  the 
patient  appeared  dead." 

Cold  affusion  to  the  head  seemed  to  produce  an  effect.  The  respiration 
then  became  agitated,  the  pulse  strong,  and  violent  convulsions,  with 
tetanic  rigidity  (pleurothotonos)  set  in. 

She  became  angry  and  irritable,  screamed  out.  Noises  in  the  room, 
light,  and  the  steps  of  persons  around  her  were  sufficient  to  "  draw  her 
from  her  attacks  of  delirium."  She  had  a  presentiment  of  sudden  death. 

"  Two  days  following  there  were  the  same  alternatives,  the  delirium 
occurring  less  frequently,  and  lasting  a  shorter  time  ;  she  slept  but  little 
that  night  (the  4th) ;  the  next  day  the  only  symptoms  noticed  were  aver- 
sion to  water,  light,  and  air,  with  the  pain  of  stomach  previously  com- 
plained of.  On  the  sixth  day  she  asked  for  a  bath,  and  the  opium  which 
she  took  in  the  evening.  A.stool  brought  on  strong  convulsions  and  noisy 

1  Forbes  Winslow's  Psychological  Journal,  vol.  ii. 


CATALEPSY.  389 

delirium.  The  women  who  were  attending  to  her  believing  her  to  be  pos- 
sessed by  the  devil,  sprinkled  her  with  holy  water,  which  increased  her 
furious  cries  and  bizarre  contortions.  The  following  night  was  dreadful ; 
the  mouth  full  of  foam,  the  eyes  injected,  and  the  delirium  almost  continu- 
ous. About  ten  in  the  morning  immoderate  laughter  succeeded  the  pre- 
vious symptoms.  She  ultimately  died." 

CASE  VII — Ward's  case.  Mary  P.,  aged  13.  Measles  at  age  of  seven, 
and  lias  ever  since  been  subject  to  cough  and  pain  in  the  side.  About 
one  year  ago  she  had  her  first  epileptic  fit,  during  which  she  attempted  to 
bite  and  scratch  the  bystanders.  She  was  not  insensible,  but  delirious. 
The  attacks  came  on  at  intervals  for  a  fortnight  afterwards,  and  they  be- 
came much  worse  at  the  end  of  this  time.  Her  arms  were  extended  and 
rigid,  and  the  fingers  clinched.  At  other  times  she  struggled  violently, 
and  the  abdomen  became  swelled.  She  never  became  unconscious.  Her 
disposition  was  changed,  for  she  grew  exceedingly  mischievous  between 
the  attacks,  developing  a  propensity  for  climbing  trees  and  playing  the 
hoyden.  Ovarian  pain  sometimes.  The  attack  is  occasionally  finished 
by  a  fit  of  laughter. 

Charcot  holds  that  a  very  important  diagnostic  sign  is  the  reduced  tem- 
perature. In  epilepsy  the  temperature  may  rise  to  107.6°  F.,  while  that 
of  the  hystero-epileptic  rarely  attains  a  height  of  100°  F.  In  the  cases  I 
have  alluded  to,  Case  I.  presented  all  the  prominent  symptoms  by  him 
enumerated,  and  still  the  temperature  was  quite  high. 


CATALEPSY. 

Definition. — A  disease  closely  allied  to  hysteria,  of  extreme  rarity, 
and  characterized  by  a  condition  of  muscular  contraction  and  semi-rigidity, 
so  that  the  limbs  may  be  placed  in  constrained  and  awkward  positions, 
and  remain  so  for  some  time.  It  is  attended  by  loss  of  consciousness  and 
cutaneous  anesthesia. 

Symptoms The  disease,  like  epilepsy,  is  characterized  by  attacks 

separated  by  intervals  of  greater  or  less  duration,  during  which  periods 
the  patient  is  usually  in  apparent  good  health. 

After  such  prodromata  as  malaise,  vertigo,  headache,  or  functional  tre- 
mor, the  individual  will  suddenly  be  seized.  He  may  be  talking  or  eat- 
ing, when  the  particular  act  is  arrested,  the  mouth  remaining  open,  or 
the  hand  half  raised.  The  muscles  become  rigid,  but  the  limb  may  be 
moved  by  the  physician  or  bystander,  and  if  placed  in  a  new  position,  no 
matter  how  awkward  it  may  be,  it  will  remain  so  fixed  until  the  muscles 
are  fatigued,  when  it  drops.  Patients  are  reported  to  have  remained  for 
even  an  hour  or  two  with  legs  or  arms  extended ;  and  in  one  case  I  saw  the 
patient  remain  for  half  an  hour  with  the  right  arm  extended  in  a  straight 
line  from  his  shoulder,  and  the  other  arm  extended  above  the  head.  The 
position  was  subsequently  changed.  The  peculiar  semi-rigidity  of  the 
muscles  has  gained  for  it  the  name  flexibilitas  cerea,  on  account  of  a 
"  wax-like"  mobility ;  and  there  is  none  of  the  pronounced  stiffness,  or,  on 


390  CEREBRO-SPINAL    DISEASES. 

the  other  hand,  limpness  of  the  limbs  that  usually  attends  the  unconscious 
state.  The  surface  of  the  body  becomes  quite  cool ;  the  pupils  are  diluted ; 
respiration  becomes  shallow  and  scarcely  perceptible ;  and  it  is  sometimes 
difficult  to  find  the  pulse,  which  becomes  thready,  but  nevertheless  pre- 
serves its  regularity. 

The  skin  is  anaesthetic  to  an  astonishing  degree.  Needles  may  be 
thrust  into  the  tissues  without  the  knowledge  of  the  individual,  and  pinch- 
ing, slapping,  or  other  forms  of  cutaneous  stimulation  produce  no  expres- 
sion of  pain.  In  a  case  of  hystero-catalepsy,  seen  with  Dr.  D.  B.  St. 
John  Roosa,  I  repeatedly  thrust  pins  into  the  arms  and  legs  of  a  young 
woman  and  watched  attentively  for  some  sign,  but  her  expression  was 
immobile  and  tranquil. 

It  is  stated  that  the  electro-muscular  contractility  is  not  affected,  but 
reflex  excitability  seems  to  be  diminished  or  lost  entirely,  so  that 
sometimes  it  is  almost  impossible  to  determine  whether  the  patient  is 
alive  or  dead.  The  so-called  trance  states  are  examples  of  this  kind,  and 
catalepsy  has  undoubtedly  led  to  burial  alive  in  many  instances. 

The  ordinary  attacks  usually  subside  in  a  few  hours,  the  rigidity  grow- 
ing less  marked,  and  consciousness  gradually  returning.  The  attacks,  as  a 
rule,  follow  each  other  in  a  series,  and  then  comes  an  interval  of  normal 
health.  In  this  mode  of  appearance  and  behavior,  the  disease  has  been 
likened  by  Eulenburg  to  neuralgia.  "  Strictly  speaking,  it  is  rather  a 
cycle  of  attacks  quickly  following  one  another  ;"  and  there  are  remissions 
characterized  by  temporary  return  of  consciousness,  and  then  a  fresh  re- 
lapse, which  evidently  follows  some  internal  irritation.  In  rare  cases 
there  is  a  sudden  return  of  consciousness  and  an  ability  to  perform  volun- 
tary acts.  The  urine  and  feces  are  rarely  passed  in  an  involuntary 
manner. 

Unless  the  disease  be  due  to  malaria,  it  becomes  chronic,  and  continues 
for  years.  If  it  is  due  to  malarial  poisoning,  it  usually  assumes  a  regular 
periodic  character,  and  is  amenable  to  treatment. 

Causes — Like  many  other  neuroses,  such  as  hysteria,  epilepsy,  and 
those  of  this  class,  mental  excitement  plays  no  mean  part  in  the  etiology 
of  catalepsy.  Fright,  and  other  forms  of  emotional  excitement  enter  into 
its  causation.  Injury  and  malaria  may  also  be  mentioned;  while  mastur- 
bation, venery,  and  intestinal  worms  are  spoken  of  by  writers  generally. 
Jaccoud  considers  it  to  be  a  result  or  accompaniment  of  certain  forms  of 
melancholia  (Melancolia  attonita),  and  ecstasy. 

It  appears  as  if  it  were  more  common  in  early  life,  and  children  are 
therefore  nearly  always  the  victims.  Anicmic  girls,  or  boys  especially 
who  study  too  constantly,  are  affected  more  often  than  those  of  adult  life. 
Nearly  all  writers  agree  that  the  female  is  more  subject  to  the  disease 
than  the  male,  and  probably  the  delicate  organization  of  the  sexual  appa- 
ratus has  much  to  do  with  this.  Hereditary  influences  seem  to  play  a 
part  in  the  etiology  only  so  far  as  the  general  neurotic  tendency  is  con- 
cerned. Families  in  which  there  are  epilepsy,  neuralgia,  and  insanity 


CATALEPSY.  391 

sometimes  include  cataleptic  members.  I  have  never  heard,  and  I  can 
find  no  record,  of  transmitted  catalepsy. 

Morbid  Anatomy  and  Pathology — Besides  the  examinations 
made  by  Calmeil  and  other  older  writers,  which,  by  the  way,  throw  very 
little  light  upon  the  question  of  pathology,  Schwartz  made  one  autopsy, 
and  Lasegue  two,  but  nothing  was  found  by  the  latter  observer. 

Schwartz1  mentions  the  case  of  a  boy  "who,  after  an  injury,  had  at  first 
attacks  resembling  chorea,  later  cataleptico-tetanic  attacks,  and  after  two 
years  died  from  anaemia  and  marasmus.  There  was  found  in  this  case, 
besides  a  serous  effusion  in  the  arachnoid,  a  softening  of  the  corpus  stria- 
turn  and  optic  thalamus,  especially  on  the  left  side ;  along  the  posterior 
surface  of  the  spinal  cord,  from  the  cervical  to  the  lumbar  enlargement, 
was  a  brownish-red,  jelly-like  mass,  arranged  in  groups,  covering  the  dura 
mater.  The  spinal  cord  seemed  healthy.  (There  was  no  microscopic 
examination.)" 

Catalepsy,  which  is  associated  with  many  other  interesting  perversions 
of  consciousness  such  as  somnambulism,  stigmatization,  etc.,  has  received  a 
great  deal  of  attention,  not  only  from  the  laity,  but  from  scientific  men  of  all 
ages.  It  is  not  my  purpose  to  enter  extensively  into  the  consideration  of 
these  various  curious  states.  The  lighter  forms,  such  as  the  "catalepsie 
passagere"  of  Lasegue,2  have  been  induced,  by  mesmerists  and  others,  by 
passing  the  hand  over  the  face  or  body,  or  by  closing  the  eyelids.  The 
same  condition  may  be  induced  by  looking  fixedly  at  some  bright  object 
held  close  to  the  face. 

A  remarkable  experiment  of  a  popular  nature,  which  I  have  repeatedly 
performed  myself,  is  a  curious  instance  of  the  susceptibility  of  certain 
animals  to  influences  of  this  kind.  If  a  lobster  is  placed  head  downwards, 
and  gentle  scratching  of  the  back  be  made,  it  will  become  perfectly  quiet, 
no  matter  how  pugnacious  it  has  been  before,  and  will  remain  in  this 
position  for  some  time. 

The  general  opinion  in  regard  to  the  pathology  of  the  affection  is  that  the 
peculiar  muscular  condition  is  due  to  an  increased  muscular  tone,  which 
probably  depends  upon  impaired  voluntary  control,  so  that  the  muscles 
respond  to  trivial  irritation  reflected  upon  the  spinal  ganglion  cells. 

Volition  is  checked  just  as  it  is  in  hysteria ;  and  when  we  consider  the 
theory  of  "  expectant  attention,"  advanced  by  Carpenter,  the  genesis  of 
some  forms  of  catalepsy  is  easily  explained.  These  are  the  varieties  in 
which  the  individual  becomes  cataleptic  when  influenced  by  another. 

Diagnosis. — The  waxy  flexibility,  which  is  pathognomonic,  is  not  a 
feature  of  any  other  disease,  and  this,  taken  in  connection  with  the  loss  of 
consciousness  and  anaesthesia,  makes  the  diagnosis  a  matter  of  certainty. 
The  only  point  which  should  interest  us  is  the  possibility  of  simulation. 
Numerous  instances  of  so-called  stigmatization  come  under  this  head. 
There  is  abundant  opportunity  for  detection,  however;  and  electricity, 

1  Quoted  by  Eulenburg  in  Ziemssen's  Encyclopaedia,  vol.  xiv.,  translation. 

2  Arcliiv.  de  M6d.,  1865. 


392  CEREBRO-SPINAL    DISEASES. 

mental  influence,  and  strong  cutaneous  revulsives  are  recommended  should 
we  suspect  malingering. 

Prognosis When  the  cause  is  emotional,  or  when  there  is  a  mala- 
rial influence,  the  individual's  chances  are  remarkably  good.  It  is  only 
when  the  disease  appears  in  a  subject  of  very  marked  nervous  tempera- 
ment that  there  is  any  reason  to  give  a  bad  prognosis,  and  such  cases  are 
chronic.  A  fatal  termination  is  a  very  remote  possibility. 

Treatment. — Electricity  in  its  induced  form  seems  to  be  indicated  for 
the  abortion  or  relief  of  the  paroxysm,  and  amyl  nitrite  may  be  recom- 
mended for  the  same  purpose.  Should  there  be  malarial  influences,  qui- 
nine, arsenic,  or  iron  is  of  course  in  order.  Curare,  bleeding,  and  many 
other  forms  of  treatment  have  been  useless.  In  the  transitory  affection 
(catalepsie  passayere)  cold  water  douches,  or  diffusible  stimulants,  are 
resorted  to. 


CHOREA.  393 


CHAPTER   XIY. 

CEREBRO-SPINAL  DISEASES  (CONTINUED). 
CHOREA. 

Synonyms — St.  Vitus's  dance  ;  St.  John's  dance  ;  Paralysis  vacil- 
liins;  Tarantismus ;  Choree,  etc. 

Definition — Chorea  is  a  disease  characterized  by  involuntary  and 
disorderly  movements  of  the  muscles,  is  unattended  by  loss  of  conscious- 
ness and  cutaneous  sensibility,  and  is  generally  connected  with  paresis  of 
certain  groups  of  muscles,  or  those  of  one  side  of  the  body. 

As  early  as  the  fifteenth  century,  a  species  of  religious  delusion  appeared 
in  Southern  and  Middle  Europe,  in  an  epidemic  form,  and  was  connected 
with  certain  saltatory  and  muscular  phenomena,  which  gained  for  it  the 
name  of  St.  Vitus's  dance. 

This  is  described  by  various  writers  as  a  condition  of  religious  excite- 
ment characterized  by  gesticulations,  contortions  of  the  body,  and  leaping, 
while  the  patient  generally  screamed  or  howled  like  an  animal.  This 
peculiar  state  was  supposed  by  the  older  writers  to  be  demoniac  possession, 
and  many  victims  were  made  to  undergo  the  ordeal,  or  were  put  to  death 
by  the  sword,  or  burnt  at  the  stake.  Under  the  influence  of  their  con- 
dition they  sought  the  shrine  of  St.  Vitus,  which  was  situated  in  a  small 
chapel  near  Zabern.  Here  they  were  cured  by  the  priests,  who  sang 
masses  and  removed  the  disorder.1 

Various  epidemics  appeared  subsequently,  but  the  disease  gradually 
became  divested  of  its  noisy  character.  In  Italy  a  dancing  disease,  sup- 
posed to  be  due  to  the  bite  of  a  spider,  and  which  received  the  name  of 
tarantism,  made  its  appearance  in  the  early  part  of  the  sixteenth  century, 
while,  at  the  same  time,  a  peculiar  outbreak  occurred  at  Amsterdam,  where 
seventy  children  of  the  Orphan  Asylum  became  possessed.  They  climbed 
the  walls,  swallowed  needles,  hairs,  pieces  of  glass,  and  other  indigestible 
substances,  and  "distorted  their  features  and  limbs  in  a  fearful  manner."2 

At  other  places  the  same  thing  occurred,  and  until  the  end  of  the  seven- 
teenth century,  when  there  Avas  some  decrease  in  superstition,  instances  of 
this  kind  of  chronic  disorder  were  common. 

Symptoms The  beginning  of  a  simple  case  of  chorea  may  be  the 

following  :  The  patient,  a  boy  of  ten  years,  who  attends  school,  becomes 
irritable,  loses  appetite,  and  does  not  care  to  go  out  and  play  with  his  fellows. 
He  becomes  pale  and  thin,  and  sits  by  himself.  In  a  little  while  some  move- 

1  Roynolds's  System  of  Medicine,  vol.  ii. 

2  Schele  de  Vere's  "Modern  Magic,"  p.  357. 


394  CEREBBO-SPINAL    DISEASES. 

ment  of  the  hand  or  fingers,  some  twitching  of  the  face,  or  dragging  of 
one  foot  when  he  walks,  attracts  the  attention  of  parent  or  teacher.  He 
may  be  punished,  with  the  idea  that  such  movements  are  the  result  of  bad 
habits  or  viciousness,  but  it  does  no  good,  but  probably  increases  the 
trouble.  These  jactitations  cease  at  night,  when  he  rests  uneasily,  and  is 
disturbed  by  bad  dreams.  This  is  the  condition  in  which  we  find  the  patient. 
What  is  the  course  of  the  disease?  If  he  is  neglected,  it  will  not  be  long 
before  the  convulsive  movements  become  general.  The  feet  may  drag 
along  as  if  paralyzed,  and  such  is  the  case.  He  will  be  unable  to  button 
his  clothing,  or  attend  to  his  little  wants,  and  may  need  the  careful  and 
constant  attention  of  his  friends.  The  vocal  cords  may  be  affected,  and 
there  is  as  a  result  a  certain  aphonia,  so  that  phonation  is  husky  and  sub- 
dued. Incoordi nation  of  the  lips  and  tongue  gives  rise  to  difficulties  in 
articulation,  which  are  quite  distressing,  the  words  being  "snapped"  and 
cut  short. 

The  symptoms  are  worthy  of  separate  consideration,  and  we  will  proceed 
to  discuss  them  in  their  order  of  importance. 

1.  Motility.* — The  spasms,  as  I  have  said,  are  clonic,  and  are  more 
often  unilateral  than  bilateral.  The  right  hand  is  usually  affected  first, 
then  the  leg  of  the  same  side  may  follow,  and  finally  the  other  side  may 
be  implicated,  so  that  the  movements  are  general.  The  arm  is  usually 
affected  before  the  face,  though  in  several  of  my  personal  cases  the  first 
symptom  noticed  was  a  slight  twitching  about  the  mouth,  and  an  awkward 
tendency  manifested  by  the  child  to  open  the  mouth  and  draw  its  breath 
while  speaking.  In  another,  the  little  boy  first  attracted  the  notice  of 
his  mother  by  movements  of  the  alse  of  the  nose. 

I  do  not  think  that  the  movements  in  chorea  are  always  increased  by 
the  effort  of  the  will  to  stop  them,  as  is  the  case  in  sclerosis,  in  which  disease 
the  tremors  are  exaggerated  by  any  voluntary  attempt  of  the  individual 
at  control ;  and  I  have  often  been  led  to  suppose  that  chorea  might  be 
divided  into  two  varieties,  viz.,  one  in  which  the  movements  are  increased 
with  the  exercise  of  the  will,  the  other  when  they  are  most  violent  in  a  state 

1  In  an  excellent  report  of  80  cases  of  chorea,*  made  by  Dr.  G.  S.  Gerhard, 
of  the  Philadelphia  Orthopaedic  Hospital  and  Infirmary  for  Nervous  Diseases,  the 
following  points  were  observed : — 

Movement. — In  27  cases,  general. 

11      "  "        but  marked  on  right  side. 

10     "  "          "         "  left       " 

32      "      unilateral,  20  on  right,  12  on  left  side. 

In  a  pertain  number  of  these  cases  the  movements  shifted  to  the  other  side. 
Paralysis. — Partial  paralysis  noted  in  17  cases.     Loss  of  power  in  10  instances 
confined  to  ri»ht  side,  in  7  to  left. 

Age. — Under  10          years,  28  cases,  9  m.,  19  fern. 
From  10  to  20      "      52      "     18    "    34    " 

Total,  80    "      27  "33     " 

Cure  in  56  eases,  improvement  or  "result  unknown"  in  24  cases. 

*  Arner.  Journ.  Medical  Sciences. 


CHOREA.  395 

of  rest.1  The  movements  of  the  hands  are  characteristic,  I  think.  There 
is  a  prehensile  movement  of  the  fingers  and  a  rubbing  of  the  ball  of  the 
thumb  and  ends  of  the  fingers.  There  is  swinging  of  the  arm,  and  a 
shrugging  of  the  shoulder,  as  if  the  patient  had  on  large  or  uncomfortable 
underclothing. 

There  is  a  trivial  point  which  may  perhaps  be  of  interest,  and  I  only 
mention  it  because  it  is  unique.  I  allude  to  the  habit  which  these  little 
patients  have  of  rubbing  the  seam  of  the  trowsers  leg  by  the  hand  which 
is  affected,  for  these  movements  often  go  on  most  actively  when  the  arm 
hangs  by  the  side,  and  when  the  attention  is  not  directed  to  it.  In  other 
diseases  just  such  "  little  straws"  will  once  in  a  while  give  a  serviceable 
hint;  for  instance,  in  commencing  paresis  of  any  kind  of  the  lower 
limbs.  If  we  examine  the  tip  of  the  shoe,  we  will  find  the  sole  to  be 
worn  down  on  one  side  of  the  body.  In  locomotor  ataxia  we  will  find  a 
reduction  of  the  heel.  When  these  little  patients  are  worried  or  embar- 
rassed, the  movements  are  greatly  increased,  and  this  is  one  of  the  strong 
features  of  diseases  of  this  kind.  I  have  at  present  a  patient  at  the  Hos- 
pital who  is  almost  quiet  when  in  the  presence  of  people  he  has  been  asso- 
ciated with  for  some  time,  but  every  new  face  seems  to  excite  him  to  such 
a  degree  as  immediately  to  give  rise  to  the  most  violent  movements. 

The  loss  of  power,  which  is  very  often  a  phenomenon  of  chorea,  is  nearly 
always  one-sided,  and  when  it  exists  to  a  marked  degree,  may  greatly 
affect  the  patient's  walk,  so  that  he  drags  his  foot  in  a  helpless  manner. 
Handfield  Jones  thinks  that  the  want  of  power  is  a  constant  feature  of  the 
disease.  Such  paresis  is  extremely  variable,  however,  in  its  extent. 
Muscular  exertion  is  distressing,  and  he  may  not  have  the  power  to  per- 
form some  of  the  least  fatiguing  actions  of  daily  life  without  great  prostra- 
tion. 

The  muscles  that  are  most  paralyzed  are  always  those  which  have  been 
the  seat  of  the  most  violent  spasm. 

Sensation There  may  be  pain  in  the  wrists  if  the  spasms  are  severe, 

or  the  skin  may  be  anaesthetic ;  such  loss  of  sensation  being  confined  to 
the  whole  paralyzed  side,  or  to  a  single  limb. 

Mental  Condition Irritability  of  temper  and  emotional  excitement 

are  present  from  the  beginning,  and  the  child  is  restless,  sleeps  badly,  and 
is  tortured  by  bad  dreams.  Study  or  mental  application  is  an  impossibility, 
and  spells  of  crying  are  quite  familiar  evidence  of  the  disease,  especially 
in  the  early  stages.  Chorea  may  exist  in  a  very  severe  form  when  there 
is  a  grave  exciting  cause  ;  and  the  convulsive  movements  may  be  so  vio- 
lent as  to  render  it  necessary  to  bind  or  hold  the  patient  in  bed.  At  the 
request  of  Dr.  J.  P.  P.  White,  of  New  York,  I  saw  with  him  a  case  of 
this  kind. 

The  little  girl,  who  was  about  ten  years  of  age,  had  arrived  in  New 
York  after  a  sea-voyage,  during  which  the  symptoms  began.  We  found 
her  agitated  by  violent  spasms  of  all  four  extremities,  which  had  lasted 

1  In  a  recent  conversation  with  my  friend  Dr.  S.  Weir  Mitchell,  lie  remarked 
that  he  had  often  recognized  the  necessity  for  such  a  division. 


396  CEREBRO-SPINAL    DISEASES. 

for  several  days,  and  it  required  constant  watching  to  keep  her  from  throw- 
ing herself  out  of  bed.  They  ceased  partially  during  sleep,  but  this  needed 
rcpo.se  was  denied  her  to  a  great  extent.  Her  skin  was  hot,  and  her 
pulse  bounding  and  full.  She  was  perfectly  conscious,  but  complained  of 
pain  in  the  wrists.  I  inferred,  from  the  general  character  of  the  convul- 
sions, their  constancy  and  violence,  and  from  other  symptoms,  that  there 
was  some  form  of  eccentric  irritation;  and  an  anthelmintic  administered 
by  Dr.  White  brought  away  a  tapeworm  several  yards  long.  The  move- 
ments disappeared  in  a  very  short  time. 

The  urine  has  been  found  by  Walshe  and  Bence  Jones  to  be  of  much 
higher  specific  gravity  than  in  health,  and  to  contain  an  excess  of  urea. 
It  may  vary  from  1030  to  1040,  and  is  loaded  with  the  oxalates  and 
lithates. 

Another  form  has  been  described  which  is  characterized  by  paroxysms, 
during  which  the  patient  may  perform  the  strangest  antics.  Her  condition 
before  and  after  the  attack  is  one  of  quietude,  but  without  warning  she  be- 
comes agitated  by  spasms,  rolls  on  the  floor,  jumps  in  the  air,  or  rushes 
about  the  room.  Wood  reports  a  case  of  this  kind  in  which  the  patient, 
a  young  married  woman  who  had  been  slightly  ill  for  some  time,  developed 
this  paroxysmal  variety.  "  The  paroxysms  themselves  were  not  always 
of  the  same  kind.  At  one  time  she  would  be  violently  and  rapidly  hurled 
from  side  to  side  in  the  chair  in  which  she  might  happen  to  be  sitting,  or 
else  suddenly  gaining  her  feet  she  would  go  on  jumping  or  stamping  for  a 
while  ;  or,  she  would  rush  around  and  around  the  room,  and  rap  with  her 
hands  each  article  of  furniture  which  lay  in  her  course ;  or  she  would 
spring  aloft  many  times  in  succession  and  strike  the  ceiling  with  the  palm 
of  her  hand,  so  that  it  became  necessary  to  remove  some  nails  and  hooks 
which  had  done  her  an  injury  ;  or  she  would  dance  upon  one  leg  with  the 
foot  of  the  other  leg  in  her  hand." 

A  professional  friend  has  recently  informed  me  of  a  case  of  this  kind 
which  came  to  his  knowledge,  in  which  the  woman  was  affected  very  much 
in  the  same  way  as  the  patient  of  Mr.  Wood,  and  that  on  one  occasion  she 
created  great  commotion  by  attempting  to  climb  one  of  the  stanchions  in 
the  cabin  of  a  steamboat. 

These  cases  are  so  rare,  however,  that  they  only  deserve  to  be  men- 
tioned en  passant  as  examples  of  the  irregularity  of  the  disease,  and  are 
somewhat  like  the  original  dances  of  St.  Vitus  and  St.  John. 

The  following  case  illustrates  a  very  curious  phenomenon  of  motility 
which  I  lately  noticed  : — 

The  patient,  a  boy  of  ten  years,  was  brought  to  me  by  his  father  for 
treatment,  after  having  been  seen  by  many  practitioners,  who  did  not  agree 
in  regard  to  his  condition.  I  saw  that  his  movements  were  choreic.  Ques- 
tioning revealed  the  fact  that  he  had  never  been  a  strong  child,  but  had 
always  been  disposed  to  nervous  troubles  ;  even  the  exanthematous  fevers, 
which,  like  other  children,  he  had  had,  were  generally  connected  with 
stupor,  and  other  evidence  of  susceptibility  of  the  nervous  substance  to 
blood-poison.  He  never  had  any  rheumatic  or  cardiac  affections,  and  I 
could  hear  nothing  to  indicate  valvular  trouble.  The  heart-sounds  were 


CHOREA.  39T 

sharp  and  quick,  however.  Four  years  ago  he  began  to  decline,  became 
weak  and  anaemic,  was  irritable,  moody,  and  bad-tempered.  His  appetite 
was  capricious,  and  he  preferred  sweets  to  other  food.  In  the  summer  of 
1872  the  movements  in  the  hands  and  arms  began,  and  soon  became  gene- 
ral. His  rest  was  uncomfortable,  and  he  started  up  in  his  sleep  and  cried 
out.  When  I  saw  him  four  months  ago  he  was  a  pitiable  object.  His 
movements  were  general.  He  was  unable  to  hold  anything,  and  was 
powerless  to  perform  any  voluntary  actions  except  those  of  a  gross  kind. 
He  could  not  unbutton  his  clothing  or  put  on  his  cap  ;  his  mother  even 
had  difficulty  in  making  him  walk. 

Variety  of  Movement — Head  was  violently  agitated,  there  being  con- 
tractions of  the  sterno-cleido-mastoideus.  He  "  sucked  in  his  cheeks,"  and 
pursed  up  his  mouth,  smacking  the  lips.  Other  facial  contortions  were 
violent.  He  winked  spasmodically,  and  there  was  constant  motion  of  the 
eyeballs. 

The  arms  were  in  constant  motion,  but  the  right  was  not  affected  so 
much  as  the  left.  The  right  arm  and  hand  were  slightly  paretic,  and  he 
was  able  to  force  the  column  of  fluid  in  the  fluid  dynamometer  up  to  1G°, 
which  is  equal  to  15  Ibs.  pressure  to  the  square  inch.  The  left  forced  it 
up  to  18°. 

The  legs.  The  right  leg  was  also  slightly  paretic.  The  toe  of  the  shoe 
was  worn  down  to  some  degree,  although  the  walk  was  not  noticeably 
affected. 

There  was  an  uneasy  rolling  of  the  pelvis  when  he  sat  down,  and  the 
legs  were  not  entirely  under  his  control.  There  was  pain  in  the  wrists 
and  ankles.  Under  proper  management  of  his  diet  he  gradually  improved, 
and  at  the  last  visit  was  nearly  well.  I  noticed  then  for  the  first  time  the 
following  peculiar  state  of  affairs.  When  sitting  in  front  of  me,  I  told  him 
to  raise  his  hands,  one  after  the  other.  The  right  hand  he  raised  promptly, 
but  the  left  he  could  not,  unless  he  took  hold  of  the  wrist  with  the  other 
hand,  and  lifted  it.  This  condition  struck  me  as  remarkable,  especially 
as  he  had  to  repeat  the  process  of  aiding  with  the  right  hand. 

The  left  hand  and  forearm  might  be  paretic.  There  was  no  loss  of 
electro-muscular  contractility,  however,  but,  if  anything,  it  was  increased. 
The  muscular  power,  tested  by  the  dynamometer,  was  found  to  be  even 
better  than  in  the  other  hand.  There  was  no  atrophy.  With  these  facts 
in  view,  it  seemed  improbable  that  this  should  be  the  cause. 

It  was  found  that  when  the  other  hand  was  held  down,  the  boy  was 
able  to  lift  his  left  hand  unassisted,  and  even  to  raise  a  dumb-bell  weighing 
10  Ibs.,  but  as  soon  as  the  other  hand  was  released  he  was  unable  to  re- 
peat it. 

To  determine  whether  this  was  the  result  of  any  bad  habit,  I  ascertained 
from  the  father  that  his  son  had  never  used  one  hand  to  lift  the  other  till 
a  few  weeks  ago. 

In  adult  life  forms  of  chorea  are  met  with  which  in  nearly  every  respect 
resemble  those  of  infancy.  Sometimes  pregnancy  is  the  cause,  and  in 
other  cases  prolonged  emotional  excitement,  and  more  especially  grief,  are 
in  some  way  connected  with  the  development  of  the  disease. 

My  case-book  contains  the  records  of  several  of  these  examples,  and 
their  form  is  usually  of  that  kind  which  is  known  as  hemichorea,  and  very 
often  seems  to  be  dependent  upon  some  true  organic  lesion.  In  this  form 
the  exercise  of  the  will  to  stop  the  movements  is  generally  provocative  of 


398  CEREBEO-SPINAL    DISEASES. 

a  decided  increase  in  their  violence.  The  patient  is  unable  to  carry 
food  to  his  mouth,  to  manage  his  clothing,  or  to  perform  any  little  acts 
of  necessity.  He  fears  to  make  any  attempts  in  the  presence  of  other 
people,  and  this  is  especially  the  case  before  strangers.  I  have  already 
alluded  to  one  instance  of  this  kind.  In  another  patient  the  mere  sugges- 
tion of  meeting  a  new  physician  was  sufficient  to  aggravate  her  convulsive 
movements. 

The  chorea  occurring  during  pregnancy  generally  disappears  before 
parturition,  and  though  Jaccoud  considers  that  it  may  lead  to  miscarriage, 
and  though  he  has  found  the  mortality  greater  than  in  any  other  form,  I  am 
not  disposed  to  agree  with  him  as  to  the  serious  character  of  the  disorder. 

An  instructive  case  of  this  disease  is  subjoined  : — 

Mary  K.,  aet.  24,  entered  the  Epileptic  and  Paralytic  Hospital  July 
10th,  1877.  She  is  of  nervous  temperament,  and  gives  a  family  history 
of  nervous  disease.  Her  sister  has  epilepsy,  and  a  brother  has  infantile 
paralysis.  Up  to  the  5th  day  of  June,  1877,  she  was  perfectly  well. 
While  in  bed  she  was  awakened  by  a  storm  at  about  3  A.  M.,  and  was 
greatly  frightened  by  the  loud  claps  of  thunder  and  the  vivid  lightning. 
She  arose  and  fell  to  the  floor,  where  she  lay  for  some  time,  crying,  but 
found  no  difficulty  in  arising,  there  not  being  paralysis.  The  next  day 
she  felt  "a  cramp"  in  the  left  side,  and  the  leg  and  arm  were  spasmodi- 
cally contracted,  and  afterwards  began  to  twitch.  There  is  no  pro- 
found loss  of  power  whatever,  but  some  slight  paresis  of  the  left  side,  and 
a  decided  hypercesthesia  of  this  part  of  the  body.  The  left  upper  and 
lower  extremities  were  convulsed  by  choreiform  movements,  the  hand 
being  more  agitated  than  the  leg.  The  strength  of  grip  is  decidedly 
weakened,  and  she  is  only  able  to  force  the  fluid  index  in  the  dynamo- 
meter up  to  8°,  while  with  the  other  hand  she  raised  it  to  1 4°.  There 
is  some  dragging  of  the  foot  when  she  walks.  She  does  not  sleep,  but 
recpjires  chloral  and  other  hypnotics.  She  is  in  her  seventh  month  of 
pregnancy,  and  it  was  decided  not  best  to  try  any  very  active  treatment. 
Arsenic  was  given,  however,  in  the  form  of  five-minim  doses  of  Fowler's 
solution,  and  she  became  more  quiet  under  its  use.  At  no  time  has  she 
shown  any  indication  of  impending  abortion,  and  though  feeble  and  anae- 
mic, she  is  able  to  go  about  and  enjoy  herself  in  a  limited  way. 

Atiff.  2~>.  Fowler's  solution  increased,  so  that  she  takes  n\,x,  t.  i.  d. 
Movements  somewhat  lighter. 

Sept.  20.  Gave  birth  to  a  healthy  boy  after  a  short  labor. 

Oct.  10.  Cured.  Discharged.  There  were  no  special  temperature 
variations  at  any  time. 

A  case  of  interest  is  that  of — 

Lena  C.,  aet.  44  ;  Germany ;  married.  Her  mother  had  chorea  at  the 
same  age.  About  four  years  ago,  without  any  appreciable  cause,  convul- 
sive movements  of  the  whole  body  began.  These  were  not  general  at  first, 
and  were  limited  oidy  to  the  upper  extremities.  The  movements  are 
bilateral,  and  agitate  the  hands  more  than  any  other  part.  The  facial 
muscles  are  slightly  affected,  and  there  is  a  jerking  upwards  of  the  corners 
of  the  mouth,  more  especially  on  the  right  side.  The  movements  are  neither 
aggravated  nor  controlled  by  the  will,  but  cease  during  sleep.  Her  cutane- 
ous sensibility  is  in  no  way  affected,  and  her  sight  and  hearing  are  both 


CHOREA.  399 

good.  She  has  a  strange  habit  of  clutching  her  dress  in  front,  probably 
to  steady  her  hands,  and  when  spoken  to  she  seems  greatly  disconcerted 
and  moves  more  than  ever. 

June  25.  Fl.  ext.  conii,  n^xl,  t.  i.  d.  ordered  by  visiting  physician. 

26th.  Xo  marked  toxic  effects  of  the  drug  apparent,  except  dilatation 
of  the  pupils  ;  and  the  patient  says  that  there  is  a  "  complete  lightness  of 
the  body,"  and  that  "she  could  fly."  Some  improvement  in  movements. 
With  a  strong  voluntary  effort  the  movements  are  stopped  for  a  time. 

July  10.  Great  improvement;  patient  can  hold  her  arms  quite  steadily ; 
medicine  stopped  (case-book  does  not  say  why).  Discharged  at  her  own 
request  Dec.  15,  1875. 

She  re-entered  Dec.  22,  1875.  I  found  the  patient  in  probably 
the  same  state  in  which  she  first  came  into  the  hospital.  She  is  a 
spare,  tall  woman,  very  restless  and  emotional.  She  cannot  express  her- 
self at  all,  for  when  she  attempts  to  speak  the  tongue  refuses  to  do  its  part 
in  articulation,  and  the  result  is  the  utterance  of  ill-arranged  sounds, 
which  are  not  properly  formed  into  words.  She  smacks  her  lips,  and 
"  clicks"  her  tongue  against  the  roof  of  the  mouth,  and  the  sounds  which 
come  forth  are  tremulous  and  agitated,  and  just  such  as  one  would  expect 
to  hear  from  a  person  who  was  agitated  by  some  great  fear.  The  con- 
tortions of  the  arms  are  very  violent  and  irregular,  and  almost  defy  de- 
scription. The  body  seems  to  twist  upon  the  pelvis ;  the  arms  are  thrown 
backwards  and  forwards,  and  the  hands  and  fingers  are  constantly  work- 
ing. She  seems  to  have  no  volitional  control  over  her  limbs,  and  has  very 
little  muscular  force.  She  walks  without  any  apparent  embarrassment, 
but  when  seated  the  movements  in  the  lower  extremities  are  more  active 
than  when  she  stands  up.  She  was  somewhat  analgesic,  as  was  demon- 
strated by  pinching.  Treatment  with  strychnine  considerably  moderates 
the  violence  of  the  spasmodic  movements. 

Chorea  may  often  present  a  periodic  character,  especially  if  malaria 
enters  into  its  causation.  The  tendency  to  relapse  is  quite  a  striking 
feature,  and,  in  many  cases  which  I  have  seen,  it  appeared  either  during 
the  early  fall  or  spring,  and  reappeared  the  following  season.  It  may  be 
accompanied  by  other  nervous  troubles,  or  exist  in  an  uncomplicated  form 
as  a  result  of  debility  arising  from  repeated  nervous  exhaustion  or  fresh 
eccentric  causes.  In  one  case  I  found  it  to  appear  as  soon  as  cold  weather 
came,  and  at  the  same  time  an  extensive  eczema  upon  the  calves  of  the  legs 
and  scalp  was  developed.  This  disappeared,  together  with  the  movements, 
under  the  use  of  arsenic  and  oil,  but  both  reappeared  the  following  winter. 
Dr.  E.  Frankel  has  reported  a  similar  case,  and  I  have  no  doubt  there  are 
others  who  have  had  a  like  experience.  The  disease  usually  wears  itself 
out  in  a  short  time,  the  tendency  to  relapse  rarely  lasting  after  puberty ;  and 
if  a  cure  can  be  effected,  the  maintenance  of  a  high  standard  of  general 
health  and  certain  precautions  as  to  overwork  or  study  prevent  a  return. 

Causes Various  writers  agree  that  the  disease  is  confined  to  the 

period  between  the  third  and  fourteenth  years,  and  this  has  been  my  ex- 
perience. I  do  not  know  of  a  case  under  three  years,  but  Hammond  has 
seen  the  disease  in  a  child  of  eighteen  months.  Watson  limits  the  time 
at  which  chorea  may  appear  to  the  period  between  the  first  and  second 


400  CEREBRO-SPINAL    DISEASES. 

dentitions ;  and  Hillier,  of  Great  Ormond  Street  Children's  Hospital,  has 
given  a  table,  which  is  referred  to  by  Radcliffe.  He  found  that  of  422 
cases  at  the  above  institution,  104  were  between  the  ages  of  ten  and 
twelve.  Girls  seem  to  be  more  often  affected  than  boys,  for  what  reason  I 
cannot  say,  except  that  it  may  be  the  more  delicate  organization  of  the 
former,  and  the  preparative  changes  going  on  before  menstruation. 

Niemeyer  believes  the  malady  to  be  very  rare  before  the  sixth  year  and 
after  the  fifteenth.  When  the  disease  appears  after  puberty,  it  generally 
takes  an  eccentric  form,  or  it  may  be  due  to  central  organic  changes,  or  fol- 
low hemiplegia.  This  latter  form,  denominated  by  Mitchell  post-paralytic 
chorea,  has  already  been  described.  In  chorea  there  is  a  general  derange- 
ment of  the  digestive  organs  and  loss  of  appetite ;  constipation  and  palpi- 
tation are  quite  common  alterations  of  function  met  with  in  these  cases. 
In  the  anaemic  patients,  and  they  are  generally  all  so,  there  is  often  an 
aortic  murmur,  and  the  skin  is  pale  and  cool. 

The  existence  of  cardiac  disease  or  the  previous  history  of  rheumatism 
is  considered  by  many  authors  to  have  much  to  do  with  the  causation  of 
the  disease.  Romberg,  Hughes,  and  West,  besides  many  others,  have  so 
decided ;  and  when  we  consider  the  pathology  of  the  disease,  it  will  ap- 
pear to  us  very  reasonable.  Of  104  cases  of  chorea  at  Guy's  Hospital,  but 
15  of  the  number  were  free  from  any  indication  of  cardiac  or  rheumatic 
difficulties. 

The  disease  often  follows  scarlatina  or  other  zymotic  febriculae,  or  takes 
its  origin  from  an  attack  of  acute  rheumatism.  It  may  result,  and  gene- 
rally does,  from  some  directly  exciting  cause,  such  as  over-study,  bad  air, 
or  food,  worms,  or  sudden  fright.  My  recent  investigations  in  regard  to 
the  occurrence  of  the  disease  among  school  children  revealed  the  astound- 
ing fact  that  over  twenty  per  cent,  of  young  school  children  of  the  public 
schools  of  New  York  were  affected  with  choretic  affections  of  greater  or 
less  gravity.  West1  expresses  it  as  his  opinion  that  over-study  is  a  com- 
mon cause,  and  my  investigations  are  sufficient  to  prove  this. 

Many  cases  are  supposed  to  result  from  association  of  unaffected  children 
with  those  who  are  the  subjects  of  chorea.  Niemeyer  alludes  to  the  prev- 
alence of  tlii.s  u  mimetic  form"  among  boarding-school  pupils.  This  view 
has  been  very  popular  with  the  laity,  and  I  am  convinced  has  some  im- 
portance, still,  I  cannot  but  think  that  the  influence  of  example  has  been 
grossly  exaggerated. 

Malaria  seems  to  play  a  decided  part  in  the  etiology  of  the  disease. 
This  was  pointed  out  by  Kinnicutt,  who  reported  some  interesting  cases 
in  which  the  movements  were  aggravated  at  certain  hours  on  alternate 
days,  and  were  characterized  by  something  like  periodicity. 

1  Am.  Psychological  Journal,  Feb.  1876.  A  number  of  papers  containing 
questions  wore  sent  to  the  public  school  teachers  of  this  city.  In  most  instances 
the  answers  were  intelligent  and  satisfactory.  The  cases  alluded  to  above  varied 
from  movement  of  the  hands  and  twitching  of  the  facial  muscles  to  general  move- 
ments which  attracted  the  attention  of  visitors. 


CHOREA.  401 

Morbid  Anatomy  and  Pathology — But  few  cases  of  fatal  chorea 
have  been  reported.  Twenty-two  of  these  are  brought  forward  by  Dr. 
Dickinson,  whose  excellent  article  upon  the  pathology  of  chorea  deserves 
the  attention  of  every  student  of  neurology.  One  case  has  been  reported 
by  Ellischer,1  which  is  instructive,  as  it  exhibits  changes  in  the  nerve- 
trunks  ;  and  Ogle,2  Kirkes,3  Hughes,4  and  Romberg5  have  made  autopsies 
in  other  cases.  In  Dickinson's  cases  the  heart  was  found  to  be  healthy  in 
five  ;  in  the  remaining  seventeen  the  following  lesions  were  observed : — 

Recent  vegetations  on  mitral  valves  only,    .         .         .  seven. 

"  "  "  "       with  old  thickening,  one. 

Recent  vegetations  on  mitral  and  aortic  valves,    .         .  one. 
Recent  vegetations  on  mitral  and  aortic  valves,  with  peri- 

cardial  adhesions,  .         .         .         .         .         .  two. 

Recent  vegetations  on  mitral  and  tricuspid  valves,        .  one. 
Recent  vegetations  on  mitral  and  tricuspid  valves,  with 

pericardia]  adhesions,      ......  one. 

Recent  vegetations  on  mitral  and  aortic  valves,  with 

recent  pericarditis,  ......  two. 

Recent  vegetations  on  mitral  valves  with  old  pericardia! 

adhesions,      ........  one. 

Of  the  patients  affected  with  recent  endocarditis,  6  originated  from 
rheumatism,  2  from  mental  causes,  3  from  uterine,  1  from  rheumatic  and 
uterine,  2  from  mental  and  uterine,  and  3  from  unknown  causes;  thus 
showing  the  connection  between  the  rheumatic  origin  and  the  cardiac 
changes. 

The  brain  and  cord  were  affected  in  11  cases,  there  being  congestion, 
softening,  and  appearances  similar  to  those  noted  by  the  other  observers  I 
have  mentioned. 

In  one  of  his  cases  (No.  V.)  he  made  very  thorough  microscopical 
examinations,  and  I  present  his  account  of  the  appearances  noted :  "  Sub- 
sequently sections  from  almost  every  region  of  the  brain  were  examined 
microscopically.  They  were  in  most  instances  natural,  the  nerve-cells 
invariably  so,  save  some  injection  of  the  vessels,  not  enough  to  be  decidedly 
morbid;  though  the  veins  were  much  distended,  in  particular  about  the 
dentate  bodies  of  the  cerebellum,  the  vessels  and  their  canals  were  nor- 
mal. There  was  no  extravasation,  effusion,  or  erosion.  Two  situations, 
however,  were  remarkable  exceptions  to  these  statements.  In  the  deeper 
white  matter  of  one  of  the  cerebral  convolutions  were  many  conspicuous 
spots,  which  consisted  of  accumulations  of  crystals  of  haematine  mingled 
with  indefinite  debris,  probably  of  nervous  origin,  swelling  the  canals 
around  arteries  which  still  remained  distended  with  blood. 


1  Archiv  fur  Path.  Anat.,  etc.,  t.  Ixi. 

2  Brit,  and  For!  Med.-Chir.  Review,  1868;  Med.  Times  and  Gaz.,  1866. 

3  London  Med.  Gazette,  1850;  Med.  Times  and  Gaz.,  1863. 

4  Guy's  Hospital  Reports,  vol.  iv.,  1846.  6  Op.  cit. 

26 


402  CEREBRO-SPINAL    DISEASES. 

"  The  other  region  referred  to  as  the  seat  of  significant  change  is  that 
of  the  corpora  striata.  These  bodies  were  more  minutely  injected  than 
the  rest  of  the  brain.  The  capillaries,  as  well  as  the  larger  vessels  of  both 
classes,  being  packed  with  blood-corpuscles  and  numerous  spots,  striking 
objects  under  the  microscope,  were  closely  set  in  their  substance.  These 
consisted  each  of  an  artery  in  section,  empty,  crumpled  and  collapsed,  and 
surrounded  by  a  mass  of  globular  debris,  which  had  been  formed  at  the 
expense  of  the  surrounding  tissue.  They  had  evidently  been  produced  by 
a  solution  or  destruction  of  tissue  around  the  vessel  consequent  upon  effu- 
sion from  it,  the  result  of  injection  which  had -now  ceased  to  exist.  In 
time  these  mixed  effects  of  extravasation  and  disintegration  would  have 
disappeared  and  left  mere  vacuities. 

"The  spinal  cord  displayed  loaded  vessels  and  eroded  fissures,  such  as 
were  seen  in  every  other  instance  examined.  In  addition  to  these  com- 
mon changes,  the  gray  matter  had  undergone  extensive  transformation  of 
the  kind  to  which  the  term  sclerosis  has  been  given.  This  was  slight  in 
the  cervical  region — extreme  throughout  the  dorsal — absent  from  the  lum- 
bar. The  change  was  confined  to  the  gray  matter,  which  it  affected  on 
the  same  side  of  the  cord  nearly  symmetrically.  In  the  dorsal  region  it 
involved  at  least  a  third  of  the  gray  matter  as  seen  in  section  ;  the 
affected  portions  on  each  side  being  adjacent  to  the  attachment  of  the 
transverse  commissure,  and  at  the  root  of  each  posterior  horn.  In  the 
cervical  region,  though  the  change  was  less  extensive,  its  position  was  the 
same.  The  altered  gray  substance  had  been  converted  into  a  wool-like 
entanglement  of  curving  areolar  fibres,  among  which  nerve-fibres  could  be 
sometimes  traced,  especially  near  the  edges,  but  from  which  all  other 
nerve-elements  had  disappeared,  leaving  a  mere  confusion  of  connective 
tissue.  The  nuclei  proper  to  the  healthy  structure  were  present,  but  had 
undergone  no  increase,  nor  was  there  any  other  evidence  of  fibroid  or  con- 
nective new  growth.  The  change  seemed  to  consist  essentially  of  a 
destruction  and  removal  of  the  nervous  elements,  their  fibroid  skeleton 
only  remaining." 

A  fatal  case  of  chorea  was  reported  by  Dr.  Jas.  H.  Hutchinson.1  The 
heart  was  found  affected,  the  aortic  valves  incompetent,  the  leaflets  being 
"swollen  and  softenod,"  and  the  aorta  was  atheromatous  above  the  sinus 
of  Valsalva. 

Ellischer,2  who  made  an  autopsy,  found  that  the  vascular  changes  in  the 
brain  were  marked,  the  walls  of  the  vessels  being  changed,  and  the  surface 
covered  by  dark  granules.  In  certain  places  the  calibre  of  the  vessels 
was  narrowed,  and  there  wjis  an  accumulation  of  blood-corpuscles,  and 
consequent  effusion  of  the  watery  parts  of  the  blood.  Some  of  the  vessels 
contained  coagula.  The  connective  tissue  about  these  vessels  was  thick- 
ened and  increased  in  size,  and  contained  yellow  pigment  and  granulated 
nuclei.  The  large;  ganglionic  cells  in  the  brain  were  filled  with  pigment, 
and  the  cell  contents  much  changed.  Sections  of  motor  nerves  exhibited 


IMiilu.  Mcd.  Times,  August  5,  1876.  2  Op.  cit. 


CHOREA.  403 

red  patches,  and  destruction  of  nerve-fibres.     These  changes  show,  then, 
great  vascular  alteration,  and  degeneration  of  normal  nerve-tissue. 

In  regard  to  the  pathology  there  is  much  dispute,  some  observers  con- 
sidering it  to  be  but  a  functional  condition,  while  others  are  well  satisfied 
as  to  its  organic  nature. 

The  original  observations  of  Kirkes  first  demonstrated  the  relation  be- 
tween chorea  and  rheumatism.  Ogle  contends  that  this  relationship  (or 
at  least  the  evidences  of  rheumatismal  causation  in  the  brain,  such  as  em- 
boli)  is  only  demonstrated  by  fatal  cases.  He  considers  the  excess  of 
fibrin  in  the  blood  to  be  only  the  result  of  the  same  influence  that  pro- 
duces the  chorea,  and  that  the  blood  state,  instead  of  being  a  cause,  may 
be  a  consequence  of  chorea,  the  result  of  tissue  metamorphosis  due  to 
excessive  muscular  action. 

He  raises  a  question  as  to  the  disappearance  of  the  movements,  and 
considers  this  condition  of  affairs  incompatible  with  organic  lesions.  This 
objection,  however,  seems  to  lack  force  when  we  remember  that  in  aggra- 
vated cases  the  movements  do  not  stop  during  sleep.  Another  fact  is  to 
be  thought  of,  and  this  is  the  tendency  to  relapse  which  the  simplest  cases 
present. 

The  embolic  theory  has  been  reported  by  nearly  every  investigator,  and 
its  strongest  supporters  are  Broadbent,  Hughlings  Jackson,  and  Bastian. 
The  original  investigations  of  Kirkes  served  as  a  basis  for  this  new  theory. 
He  found  that  particles  of  fibrine  were  washed  into  the  cerebral  vessels. 
Hughlings  Jackson  located  the  place  of  final  deposit  in  the  gray  matter  of 
the  convolutions  in  the  neighborhood  which  are  supplied  by  the  middle 
cerebral  artery.  Jackson  very  cogently  considers  the  significance  of  its 
one-sided  character  as  compared  with  hemiplegia  from  embolism,  and  has 
since  brought  up  the  question  of  involvement  of  the  muscles  more  con- 
cerned in  special  voluntary  acts,  which  are  likewise  conspicuously  affected 
in  hemiplegia  and  epilepsy. 

Against  this  theory,  some  writers  have  raised  the  question  in  regard  to 
the  existence  of  the  hemichorea  on  the  same  side  of  the  body  as  that  of 
the  brain  where  the  lesion  is  found,  and  contend  that  there  must  be 
crossed  action. 

Dupuy  and  Brown -Se'quard  have  made  experiments  which  prove  that 
such  a  condition  of  affairs  may  exist,  and  I  have  myself  done  the  same 
thing.  Since  my  experiments,  I  have  heard  of  a  case,  related  by  Dr. 
Walter  Hay,  of  Chicago,  in  which  post-mortem  examination  revealed  a 
cerebral  hemorrhage  on  the  side  of  the  hemiplegia. 

In  one  of  these  experiments  made  by  Dr.  F.  H.  Rankin  and  myself  upon 
a  monkey,  electrical  irritation  (galvanic)  of  the  white  matter  just  beneath 
the  cortex  of  the  left  ascending  parietal  convolution  produced  convulsions 
in  both  extremities  of  the  same  side. 

Broadbent  localizes  the  lesions  entirely  within  the  corpus  striatum.  He 
also  calls  attention  to  the  existence  of  peripheral  irritation,  shock,  and 
various  causes  which  may  produce  a  depraved  functional  condition. 

Bastian  adopts  the  theory  that  the  emboli  consist  of  masses  of  agglome- 


404  CEREBRO-SPINAL    DISEASES. 

rated  white  corpuscles,  and  that  the  location  of  the  lesion  is  in  the  corpus 
Btriatum. 

Dickinson  is  disposed  to  regard  the  chorea  as  the  result  of  rheumatism 
rather  than  of  endocarditis,  and  considers  the  central  condition  one  of 
hypera-mia  of  the  nervous  centres,  "  not  due  to  any  mechanical  mischance, 
but  produced  by  causes  mainly  of  two  kinds:  one  a  morbid,  probably  a 
humeral,  influence  which  may  affect  the  nervous  centres  as  it  affects  otli'-r 
organs  and  tissues  ;  the  other,  irritation  in  some  mode,  usually  mental. 
but  sometimes  what  is  called  reflex,  which  especially  belongs  to  and  dis- 
turbs the  nervous  system,  and  affects  persons  differently  according  to  the 
inherent  mobility  of  their  nature." 

In  regard  to  localization  he  agrees  in  the  main  with  the  other  observers. 
''The  spots  of  peri  vascular  change  are  widely  scattered  throughout  that 
large  region  which  lies  interiorly  to  the  cerebral  convolutions  between  the 
corpora  striata  and  the  lower  end  of  the  cord ;  the  district  of  the  motor 
and  sensory  as  distinguished  from  the  mental  functions." 

It  seems,  then,  that  the  quality  of  the  lesion  is  only  disputed.  I  am 
.strongly  inclined  to  accept  the  embolic  theory,  not  only  because  the  pare- 
sis of  the  limb  may  precede  any  muscular  movements,  but  because  lesions 
in  or  about  the  corpora  striata,  which  produce  hemiplegia,  may  also  give 
rise  to  chore ic  movements. 

Diagnosis. — The  movements  of  chorea  must  be  differentiated  from 
those  of  sclerosis  and  paralysis  agitans.  This  will  not  be  a  difficult  task, 
as  the  peculiarity  of  the  choreic  movement  is  t\\ejerk^  while  the  tremor  of 
the  other  affection  is  rhythmical  and  usually  Jine,  and  varies  under  certain 
circumstances.  The  rapid  recovery  should  also  be  an  element  in  the 
diagnosis. 

That  chorea  may  result  in  some  secondary  disease,  such  as  softening  or 
meningitis,  is  well  settled  ;  and  in  these  cases  it  will  be  necessary  to  take 
into  account  the  character  of  all  the  new  symptoms,  and  the  history  of  the 
old  ones. 

The  exceptional  forms  of  the  disease  may  be  mistaken  for  hysterical 
troubles,  and  then  the  diagnosis  will  be  difficult.  It  must  be  borne  in 
mind,  however,  that  this  mistake  can  be  made  only  in  adult  cases.  The 
paralysis  of  chorea  may  be  differentiated  from  true  cerebral  or  spinal  para- 
lysis by  its  gradual  development,  and  by  the  age  of  the  individual,  as  these 
two  forms  are  quite  rare  in  infancy.  Choreic  movements  usually  stop  at 
night,  and  the  exceptions  to  the  rule  of  quiescence  during  sleep  include 
those  in  which  the  patients  have  "dreams  of  movement,"  such  as  were 
alluded  to  by  Marshall  Hall. 

Prognosis — Chorea  is  an  affection  which  may  very  often  disappear, 
without  any  treatment  whatever,  in  from  six  weeks  to  four  months;  but 
there  are  very  likely  to  be  relapses.  If  properly  treated,  the  movements 
should  disappear  in  from  six  weeks  to  two  months,  or  even  in  a  shorter 
time.  If  the  disease  appears  after  puberty,  the  prognosis  is  unfavorable, 
and  all  we  can  do  in  some  cases  is  to  moderate  its  violence.  There  is 
a  tendency  to  recovery  in  other  cases,  among  them  those  of  pregnancy. 


CHOREA.  405 

Death  is  a  very  unusual  termination,  and  it  rarely  occurs  as  a  result  of 
the  disease  itself,  but  rather  of  some  cardiac  complication. 

Treatment — Internal  remedies  :  Strychnia ;  arsenic  ;  iron  in  its 
various  forms  (bromide,  carbonate,  etc.)  ;  phosphorus  and  cod-liver  oil. 
External  remedies :  Cold  to  spine — ice,  ether  spray,  and  cold  douche ; 
Russian  or  Turkish  baths;  and  salt  baths.  Rest,  diet,  and  fresh  air. 
(FF.  7,  9,  10,  11,  13,  14,  24,  28,  29,  32,  42,  43,  51,  58,  72.) 

Some  of  these  may  be  combined  with  good  effect.  The  plan  of  treat- 
ment I  generally  employ  is  the  following:  Should  the  child  be  "run 
down,"  as  is  generally  the  case,  I  begin  with  some  preparation  of  iron, 
and  administer  at  the  same  time  cod-liver  oil.  As  regards  special  treat- 
ment, I  find  strychnine  serviceable,  carried  up  to  the  point  where  stiffness 
of  the  sural  muscles  is  arrived  at.  Next  to  this  stands  arsenic.  It 
must  be  given  in  large  doses ;  but  when  we  find  that  digestive  troubles 
are  produced  very  quickly  by  this  drug,  strychnia  may  be  substituted. 
Cold  to  the  spine  cannot  be  overestimated  as  a  plan  of  treatment.  "NW 
may  either  use  the  ether  spray,  which  was  first  suggested  for  use  in 
this  disease  by  Subetski,  of  Warsaw,  in  I860,  or  apply  ice-bags  every  day, 
allowing  them  to  stay  on  about  ten  minutes.  Perroud,  who  has  used  the 
ether  spray,  makes  applications  from  four  to  eight  minutes  in  duration 
every  day.  Of  thirty-five  cases  I  have  treated  in  this  way  (I  mean  with 
the  ether  spray),  from  fifteen  to  twenty  applications  produced  permanent 
benefit ;  and  here  I  would  say  that  the  spray  should  be  directed  chiefly  to 
the  upper  part  of  the  cord,  over  the  upper  cervical  vertebra}.  Eserine  has 
been  lately  recommended,  and  Bouchut  has  given  the  results  of  437  cases, 
205  of  whom  took  it  in  pilular  form,  and  232  hypodermically.  The  ave- 
rage dose  was  from  two  to  five  milligrammes.  He  obtained  temporary 
benefit,  which  seemed  to  wear  off;  but  when  the  drug  was  repeatedly  ad- 
ministered, he  accomplished  many  cures.  He  reports  twenty-three  cures 
by  an  average  of  seven  injections.  It  is  a  dangerous  remedy,  however, 
and  produces  severe  gastric  symptoms. 

The  salts  of  zinc  have  occasionally  proved  valuable  in  cases  of  this  dis- 
ease ;  and  conium  is  occasionally  efficacious,  but  its  effects  are  temporary ; 
but  I  prefer  the  remedies  I  have  mentioned.  I  have  found  phosphorus, 
with  cod-liver  oil,  to  be  a  most  valuable  curative  agent,  and  in  cases  where 
everything  else  failed  it  has  succeeded.  This  seems  reasonable,  when 
we  consider  how  much  impaired  must  be  the  nutrition  of  the  nervous 
matter. 

Da  Costa1  and  Mills,2  of  Philadelphia,  have  used  the  bromide  of  iron  ; 
but  the  latter  has  had  very  unsuccessful  results.  In  twelve  patients  to 
whom  he  administered  the  drug,  there  was  no  improvement  after  its  use. 

Dr.  Mills  says :  "  It  was  usually  given  in  plain  syrup  and  water,  com- 
mencing with  five  grains  three  times  daily,  as  recommended,  and  rapidly 

1  Med.  and  Surg.  Reporter,  Jan.  30,  1875. 

2  Phila.  Med.  Times,  Sept.  25,  1875. 


406  CEREBRO-SPINAL    DISEASES. 

increasing  the  dose  to  twenty.  The  treatment  was  continued  from  two  to 
four  weeks.  Twenty  grains  very  generally  caused  vomiting.  It  seems  to 
be  a  remedy  which  quickly  irritates  the  intestinal  tract." 

Oulinent  and  Laurent  recommend  hyoscyamin  in  doses  of  one-sixtieth  of 
a  grain,  in  pill  form,  at  first  twice  daily,  and  afterwards  more  frequently. 
Amelioration  is  said  to  begin  in  eight  or  nine  days.  Should  the  presence  of 
worms  be  suspected,  we  may  either  use  an  injection  of  quassia  and  carbolic 
acid  solution  (gtt.  x — Oj)  after  each  stool,  or  pursue  the  ordinary  santonine 
treatment.  The  use  of  ferruginous  tonics  is  generally  indicated,  and  those 
should  be  selected  which  are  best  assimilated  and  which  tax  digestion  the 
least.  I  would  therefore  recommend  either  the  carbonate  of  iron,  or  dya.l- 
ized  iron.  The  addition  of  digitalis  seems  to  increase  their  good  effects 
quite  materially.  Chalybeate  waters  are  useful,  and  sulphur  baths  arc 
recommended  by  Baudelocque  and  others. 

Trousseau  recommends  morphine  and  strychnine,  but  I  have  never  seen 
any  good  results  follow  the  use  of  the  former ;  of  the  virtues  of  the  latter 
I  have  already  spoken.  II.  C.  Wood  recommends  a  tincture  made  from 
the  fresh  leaves  of  the  skunk-cabbage,  with  which  he  has  had  some  suc- 
cess. Electricity  I  have  no  faith  in,  except,  perhaps,  when  the  so-called 
"  general  electrization"  is  used  as  a  cutaneous  and  muscular  stimulant. 
Benedikt  has  cured  many  cases  by  galvanism  ;  but,  as  far  as  I  can  learn, 
his  results  are  exceptional. 

There  are  instances  where  nothing  does  good.  It  is  well  to  put  the 
patients  in  a  dark  room,  and  keep  them  perfectly  quiet.  We  will  be  often 
astonished  at  the  result.  There  are  little  things  that  must  be  watched. 
The  diet,  above  all  things,  should  be  regulated  with  judgment.  Plenty  of 
fresh  air  and  sleep  come  next,  and  absolute  mental  rest  must  be  enforced. 
The  school-books  and  the  school-room  are  to  be  parted  from,  and  agree- 
able diversions  planned.  An  excellent  auxiliary  to  our  medication  is  the 
salt-bath.  A  handful  of  rock-salt  in  the  water,  and  the  energetic  use  of 
the  rough  towel,  will  infuse  a  tone  and  vigor  that  will  soon  become  appa- 
rent. In  conclusion,  I  must  say  that  decided  medication  is  useless  in 
these  patients  if  their  personal  habits  are  not  looked  after. 


PARALYSIS  AGITANS. 

Synonyms — Shaking  palsy  ;  Parkinson's1  disease  ;  Trembling  palsy; 
Tremblement  ^diiile  ;  Chorea  senile  ;  Chorea  festinans. 

It  is  unfortunate  that  so  much  confusion  exists  in  regard  to  the  proper 
classification  of  this  tremor  of  old  age.  It  has  been  and  is  to  this  day 
confounded  with  cerebro-spinal  sclerosis. 

I  shall  speak  of  it  as  a  disease  of  advanced  life,  symptomatized  by  paresis, 
involving  usually  the  upper  extremities,  with  tremor  which  is  not  increased 
by  voluntary  muscular  action.  This  tremor  rarely  affects  the  muscles  of 

1  Essay  on  Shaking  Palsy,  London,  1817. 


PARALYSIS    AGITANS.  407 

the  face,  except  in  advanced  stages  of  the  disease,  and  is  accompanied  by 
festination,  and  in  certain  cases  by  bending  of  the  body  forwards,  and 
inclination  of  the  chin  forwards  and  downwards. 

Symptoms. — The  extremities  first  become  the  seat  of  tremor,  the  fin- 
gers being  agitated  in  the  beginning  ;  the  hand  is  next  involved,  and  after- 
ward the  arm.  This  tremor  is  bilateral,  and  it  may  not  make  further 
advances  for  some  time,  but  ultimately  the  head  and  other  limbs  are 
included.  The  tremor  may  involve  one  hand  before  the  other,  or  the  leg 
of  the  same  side  may  be  next  affected,  then  the  leg  of  the  other  side,  and 
next  the  opposite  arm.  After  a  variable  time,  extending  from  one  to  ten 
years,  a  species  of  muscular  rigidity  takes  place,  so  that  the  head  is  drawn 
down,  and  ultimately  the  body  is  bent  and  the  head  is  thrust  forwards,  or 
the  chin  is  drawn  down  to  the  breast.  The  forearms  and  hands  are  flexed, 
and  the  arms  may  be  drawn  to  the  side  of  the  body.  The  constant  move- 
ments may  produce  an  actual  abrasion  of  the  skin  by  friction  of  the  elbows 
or  hands,  should  the  muscular  contraction  bring  them  in  contact  with  the 
body.  Any  attempt  at  locomotion  is  attended  by  what  has  been  called 
"  festination."  The  patient  may  rise  slowly  from  his  seat,  and  perhaps 
in  the  early  stages  walk,  slowly  though  awkwardly,  by  taking  long  strides, 
but  when  the  muscles  of  the  back  lose  their  power,  and  the  body  pitches 
forward,  the  patient's  attempts  to  preserve  his  equilibrium  result  in  a 
shuffling  gait,  and  finally  he  is  compelled  to  run  and  gladly  clutches  the 
nearest  chair  or  support  to  avoid  falling. 

The  voice  is  weak  and  the  speech  broken  and  abrupt,  and  the  form  of 
interruption  has  been  compared  by  Charcot  "  to  that  which  affects  a  novice 
in  equitation  when  his  horse  begins  to  trot."  This  interruption  is  caused 
by  the  violence  of  the  muscular  movements.  The  patient  pitches  his  voice 
when  he  begins  to  speak,  and  never  changes  the  tone  until  he  has  finished, 
so  that  his  phonation  is  decidedly  monotonous.  He  is  greatly  fatigued  by 
the  constant  muscular  movements,  and  is  restless  and  inclined  to  seek  new 
positions  which  may  give  him  ease.  A  disagreeable  symptom  is  the  oc- 
currence of  cramps  of  temporary  duration,  which  are  more  common  during 
the  day.  During  the  tremor  the  fingers  or  toes  may  be  rigidly  flexed  or 
extended.  The  face  is  utterly  devoid  of  expression,  but  the  mind  is  never 
impaired,  and  there  are  no  affections  of  the  organs  of  special  sense.  The 
tremor  in  the  beginning  ceases  at  night,  but  in  the  established  form  it  is 
present  at  all  times. 

The  termination  of  the  disease  may  be  in  death  through  exhaustion  or 
complicating  diseases,  such  as  pneumonia,  which  carried  off  three  cases 
reported  by  Trousseau.  The  functions  of  the  bladder  and  rectum  are  not 
usually  involved,  except  when  the  disease  has  become  confirmed.  In  one 
case  Topinard  found  sugar  in  the  urine,  but  it  is  hardly  necessary  to  say  that 
this  circumstance  is  exceptional. 

After  suffering  for  a  number  of  years  the  patient  is  finally  obliged  to 
seek  his  bed,  sloughs  form  over  the  sacrum,  and  he  gradually  sinks,  the 
tremor,  perhaps,  moderating  slightly  before  death. 


408  CEREBRO-SPINAL    DISEASES. 

The  following  interesting  csise  is  one  that  illustrates  the  course  of  the 
disease  perfectly  : — 

Mr.  M.,  the  patient,  during  his  early  years  led  an  active  life,  and  after 
following  the  occupation  of  a  peddler  gradually  worked  his  way  up  t<» 
prosperity.  For  years  he  went  about  the  streets  of  New  York  carrying. 
many  hofks  in  the  day,  a  heavy  pack  upon  his  hack,  and  during  this  time 
he  suffered  many  privations  of  food,  rest,  and  sleep,  and  was  exposed  to 
the  elements,  after  going  home  wet  and  cold.  Ahout  fifteen  years  ago  he 
first  noticed  the  appearance  of  his  present  disease.  He  is  a  stout  man  of 
large  frame,  and  about  70  years  old.  The  trembling  began  after  slight 
exertion,  and  continued  for  some  time.  It  became  more  pronounced  and 
constant  during  the  next  two  or  three  years,  and  he  was  unable  to  un- 
button his  clothing,  feed  himself,  or  use  his  hands.  His  general  health 
did  not  seemingly  suffer,  but  he  was  "  nervous"  and  depressed,  and  fully 
aware  of  his  pitiable  state.  He  did  not  tremble  so  much  when  lying  down, 
but  when  he  moved  about  or  assumed  the  erect  position  the  hands  shook 
and  the  head  shook  constantly  from  side  to  side.  The  movements  always 
stopped  at  night,  but  it  was  some  time  before  he  could  sleep.  He  gradu- 
ally lost  power;  the  right  arm  losing  strength  primarily,  and  afterwards 
the  left.  Coincident  with  the  loss  of  power  there  was  tremor.  AVhen  I 
saw  him  two  years  ago,  I  found  him  seated  in  a  chair  in  which  he  had 
difficulty  in  keeping  his  place.  His  upper  extremities  and  head  were 
chiefly  affected.  The  head  was  inclined  forwards,  and  was  constantly 
agitated  by  movements  of  a  rhythmical  character,  which  did  not  appear  to 
be  increased  or  diminished  by  any  act  of  volition.  He  could  not  raise  his 
chin,  but  looked  up  at  me  when  I  entered  the  room  with  his  son.  When 
asked  a  question,  he  answered  in  a  tremulous  voice,  speaking  as  would  one 
wlio  was  chilled.  His  body  was  curved  forwards,  and  his  arms  were  semi- 
fiexed,  the  elbows  being  drawn  to  the  chest ;  and  forcible  or  voluntary 
extension  was  impossible.  There  was  no  atrophy  of  the  muscles  of  the 
arms  or  forearms,  and  no  decided  loss  of  sensation.  The  hands  were  agi- 
tated by  the  same  rhythmical  tremors  as  the  head.  When  he  was  lifted  up 
he  could  not  walk,  and  would  have  pitched  forward  if  not  held.  In  this 
position  I  noticed  that  the  knees  were  also  affected  by  the  tremor.  His 
bladder  and  rectum  did  not  seem  to  be  involved,  at  least  not  as  a  result  of 
the  disease,  for  beyond  symptoms  of  enlarged  prostate  he  suffered  no  im- 
pairment of  function.  For  the  past  two  years  he  has  needed  powerful 
opiates  to  procure  sleep,  the  movements  continuing  unless  they  are  given. 
He  swallows  with  difficulty,  and  there  is  a  drain  of  saliva  from  the  corner 
of  his  mouth.  As  far  as  I  can  learn  there  have  been  no  disorders  of  the 
organs  of  special  sense,  and  certainly  there  are  now  none.  His  mind  seems 
to  be  somewhat  affected,  as  he  is  irritable  and  silly,  and  his  memory  is 
deficient. 

It  may  be  stated  that  the  affection  may  exist  in  a  modified  form  (Parkin- 
son's disease),  and  that  tremor  alone  may  be  the  only  symptom.  Festi- 
nation  and  rigidity  are  by  no  means  constant  expressions  of  the  affection. 

Causes — Nothing  is  known  in  regard  to  the  causes  of  paralysis  agi- 
tans.  It  has  followed  mental  distress,  or  has  been  preceded  by  neuralgia 
and  rheumatism,  but  these  seem  to  be  connected  with  so  many  nervous 
diseases  that  it  is  difficult  to  say  just  how  much  they  have  to  do  with  the 
etiology  of  paralysis  agitans.  I  have  seen  seveial  cases,  and  in  none  of 


PARALYSIS    AGITANS.  409 

them  was  there  any  history  of  predisposing  or  exciting  causes.  We  know 
that  the  disease  is  rare  before  the  fortieth  year,  and  that  the  male  sex  is 
more  often  affected  than  the  other  sex. 

Morbid  Anatomy  and  Pathology — Handfield  Jones1  and  Ham- 
mond2 are  supporters  of  the  doctrine  that  the  affection  is  purely  of  a  func- 
tional character  ;  and  the  latter  is  of  the  opinion  that  the  paralysis  agitans 
of  Charcot  is  a  multiple  cerebral  sclerosis.  In  an  excellent  review  of  the 
recent  writings  of  Charcot  and  Moxon,  which  has  appeared  lately,  the 
reviewer  says  :  "  There  is  a  certain  satiric  humor  in  Prof.  Charcot's  notice 
of  the  morbid  anatomy  of  paralysis  agitans.  He  divides  the  autopsies 
hitherto  made  into  three  groups.  In  the  first  group  nothing  at  all  was 
found.  The  second  group  comprises  cases  of  supposed  paralysis  agitans, 
which  Prof.  Charcot  considers  were  in  reality  sclerosis ;  and  the  third 
group  contains  the  case  of  Parkinson  subsequently  mentioned,  and  a 
similar  case  by  Oppolzer,  which  is  treated  with  similar  distrust.  There 
are,  however,  other  cases  on  record  which  give  much  more  satisfactory 
results.  Leyden  has  reported  one  in  which  the  agitation  was  limited 
to  the  right  arm,  and  a  sarcoma  the  size  of  a  large  nut  was  found  in 
the  optic  thalamus  of  the  opposite  side.  Murchison  and  Cayley  have 
reported  a  case  in  which  very  definite  changes,  partly  of  sclerosis  and 
partly  of  cell  growth,  were  found  in  the  cord;  but  as  in  this  case 
the  symptoms  are  described  but  very  briefly,  it  is  possible  that  Prof. 
Charcot  would  place  it  in  his  second  group.  Joffroy,  however,  took 
especial  care  to  investigate  this  point,  as  to  whether  the  cases  were  really 
paralysis  agitans  or  insular  sclerosis,  and  he  states  that  two  out  of  his  three 
cases  were  clearly  paralysis  agitans.  In  these  two  cases  there  was  exube- 
rant growth  of  the  epithelium  of  the  central  canal  and  of  the  nuclei  around. 
In  the  third  case,  which  seems  not  to  have  been  a  very  doubtful  one,  there 
Avas  in  addition  a  sclerosed  patch  in  the  medulla."3 

The  pathology  of  tremor  is  still  so  imperfectly  understood,  and  there  is 
so  much  to  be  said,  that  it  would  involve  a  much  more  protracted  con- 
sideration than  the  size  of  this  book  will  permit.  We  may,  however,  con- 
sider some  of  the  physiological  conditions  of  muscles  which,  when  disturbed, 
result  in  the  pathological  state  known  as  tremor. 

The  variation  or  interruption  of  any  compound  entity  is  followed  by  an 
inharmonious  relation  of  its  parts  ;  thus  a  musical  sound  is  the  result  of  a 
number  of  more  or  less  rapid  vibrations  and  waves,  their  number  influencing 
pitch.  If  a  catgut  string  in  a  state  of  tension  is  twanged,  vibrations  are  in- 
duced and  a  musical  tone  is  produced  ;  but  if  a  stick  be  loosely  held  against 
the  string,  without  actual  pressure  being  made,  the  vibrations  will  be  inter- 
rupted, and  a  discordant  noise  will  be  the  result  of  such  contact.  It  has 
been  demonstrated  that  a  visible  muscular  contraction  is,  after  all,  the  re- 
sult of  an  incredible  number  of  smaller  contractions,  which  cannot  be  seen 

1  Functional  Nervous  Diseases,  p.  382. 

2  Diseases  of  the  Xervous  System,  p.  785. 

3  Brit,  and  For.  Med.-Chir.  Rev.,  Oct.  1875. 


410  CEREBRO-SPINAL  DISEASES. 

with  the  nuked  eye,  but  may  easily  be  appreciated  with  the  aid  of  the 
myographium  or  some  other  registering  instrument.  Upon  faradizing  a 
muscle  this  may  be  experimentally  demonstrated.  Short  breaks  are  fol- 
lowed by  visible  contractions  of  the  muscle  and  movements  of  the  liml> ; 
but  if  by  a  proper  current-breaker  this  interruption  be  repeated  many 
hundred  times  a  minute,  the  intervals  will  be  so  short  that,  though  an  im- 
mense number  of  rapid  contractions  take  place,  there  is  but  one  grand 
contraction  of  the  muscle  which  is  appreciable. 

In  the  physiological  state  this  coordination  (if  I  may  use  the  word)  of 
the  minor  contractions  is  so  perfect  that  the  muscular  movements  are  steady 
and  separated  by  regular  intervals ;  but  when  the  rhythm  is  lost,  or  the  har- 
mony destroyed,  the  smaller  contractions  will  be  separated  by  intervals  of 
sufficient  length  to  be  seen,  and  tremor  results,  the  degree  of  tremor 
being  proportionate  to  the  length  of  the  interval. 

The  filaments  of  a  tired  muscle,  the  motor  centres  being  worn  out,  do 
not  contract  evenly ;  so,  as  a  consequence,  there  is  a  visible  tremulous- 
ness.  In  functional  tremor,  such  as  characterizes  the  disease  in  question, 
this  is  undoubtedly  the  pathological  condition. 

Diagnosis The  tremor  of  cerebro-spinal  sclerosis  may  be  mistaken 

for  that  of  paralysis  agitans.  Let  us  compare  the  points  of  difference  : — 

PARALYSIS  AGITAXS.  CEREBRO-SPINAL  SCLEROSIS. 

Tremor  continuous,  but  not  increased  Tremor  subsides  during  repose,  and 
by  voluntary  efforts.  is  always  aggravated  by  volitional  at- 

tempts at  control. 

Tremor  regular  and  "fine."  Tremor  "coarse." 

Facial  muscles  unaffected.  Usually  cranial   nerve   paralysis,  or 

tremor  of  facial  muscles. 

Runs  forward  to  preserve  balance.  Only  staggers  when  walking   is   at- 

tempted. 

Speech  slow,  or  affected  by  violence  Speech-defects  those  which  arise 
of  muscular  movements.  from  paralysis. 

A  disease  of  old  age,  or  advanced  Usually  a  disease  which  appears  be- 
life.  fore  middle  age. 

Mercurial  tremor,  lead  tremor,  and  alcoholic  tremor  sometimes  resemble 
that  of  the  disease  in  question  ;  the  former  is,  however,  more  violent  in  the 
morning ;  the  tremor  from  lead  is  attended  usually  by  colic  and  other 
symptoms  of  plumbism  ;  while  no  doubt  need  arise  in  regard  to  the  third, 
which  is  attended  by  evidences  of  alcoholism.  Post-paralytic  chorea  may 
be  excluded  by  the  history  of  hemiplegia  or  some  other  equally  prominent 
organic  condition,  and  the  tremor  is  aggravated  by  voluntary  efforts.  A 
functional  tremor  of  a  very  light  grade,  which  is  simply  a  personal  pecu- 
liarity, is  met  with  sometimes,  and  should  not  be  magnified  to  the  dignity 
of  a  disease.  This  may  affect  several  members  of  the  same  family,  as  is 
the  case  in  one  example  of  which  I  know.  The  head  of  the  family  is  a 
vestryman  of  an  Episcopal  church,  and  in  passing  the  plate  he  sometimes 
is  obliged  to  exercise  the  utmost  self-control  to  prevent  the  contents  from 
being  thrown  out,  and  more  than  once  this  infirmity  has  given  rise  to 


PARALYSIS    AGITANS.  411 

insinuations  concerning  his  habits.  His  two  children,  both  very  young 
and  healthy  people,  are  affected  by  the  same  tremor.  In  such  a  case  the 
trouble  does  not  increase  with  time,  and  there  are  none  of  the  other  pro- 
gressive signs  of  the  time  affection. 

Prognosis. — The  course  of  paralysis  agitans  is  decidedly  progressive, 
though  very  gradual,  and  the  individual  may  live  for  ten,  twenty,  or  even 
thirty  years  after  the  appearance  of  the  tremor.  When  death  takes  place, 
it  is  in  nine  cases  out  of  ten  the  result  of  some  other  disease.  I  am 
convinced  that  genuine  paralysis  agitans  is  never  cured,  though  it  may  be 
relieved ;  and  it  is  highly  important  to  distinguish  simple  functional  tremor, 
Avhich  is  not  uncommon,  from  the  disease  under  consideration.  This 
functional  disorder  is  amenable  to  treatment. 

Treatment — Handfield  Jones1  considers  that  nothing  can  be  done 
for  the  disease  among  very  old  people  when  it  has  become  decidedly 
chronic.  He  has  used  electricity,  conium,  and  a  variety  of  remedies. 
"  The  general  tenor  of  experience  in  this  and  in  kindred  disorders  is  to 
the  effect :  (1)  that  the  main  indication  is  to  nourish  and  support  the  fail- 
ing power  of  the  nervous  centres  affected ;  (2)  that  this  is  best  accom- 
plished by  remedies  drawn  from  the  class  of  sedatives,  or  by  the  milder 
tonics.  Henbane,  conium,  chloral,  subcutaneous  opiates,  bromide  of  potas- 
sium, belladonna,  hypophosphites,  or  phosphorus,  cod-liver  oil,  carbonate 
of  iron,  and  sulphuret  of  potassium  baths,  with  electricity  in  one  or  other 
of  its  three  forms,  appear  to  me  the  most  hopeful  remedies.  But  steady 
persistence  in  appropriate  treatment  is  doubtless  essential,  and  the  want  of 
this  may  account  for  many  failures.  Trousseau's  adage  should  be  borne  in 
mind,  '  A  longue  maladie,  longue  traitement.'  " 

He  refers  to  a  cure  reported  by  another  observer.  The  patient  was  a 
woman,  eighty  years  old,  in  whom  the  disease  followed  severe  labor;  and 
she  was  ultimately  unable  to  carry  trays  or  heavy  loads.  The  faradic  cur- 
rent used  several  times  effected  the  disappearance  of  the  tremor.  I  am 
inclined,  however,  to  consider  this  case  one  of  functional  tremor,  and  not 
of  the  grave  variety  I  have  described. 

I  have  used  conium  with  good  results,  and  find  that  it  relieves  the  patient, 
but  after  the  use  of  the  drug  has  been  discontinued  for  a  few  weeks,  the 
tremor  is  pretty  sure  to  reappear.  It  should  be  given  in  doses  of  the  fluid 
extract  of  from  MLv-n^viij  thrice  daily. 

Elliotson2  has  cured  a  case  by  the  carbonate  of  iron  in  large  closes,  and 
strychnine  has  been  suggested,  but  it  is  doubtful  whether  it  does  any  real 
good. 

Galvanization  of  the  spine,  one  pole  placed  over  the  spine,  and  the 
other  as  near  as  possible  to  the  point  of  exit  of  the  spinal  nerves,  has  been 
advised ;  and  in  some  instances  it  has  improved,  if  it  has  not  cured,  the 
affection.  . 

1  Brit.  Med.  Journ.,  March  8,  1873. 

2  Quoted  by  Jaccoud,  op.  cit.,  vol.  i.  p.  427. 


412  CEREBRO-8P1NAL    DISEASES. 


EXOPHTHALMIC  GOITRE. 

Synonyms Bsisedow's  disease  ;  Graves'  disease  ;  Exophthalmic 

cached  ique  ;  C'ardiogmus  strumosus. 

This  interesting  disease  has  i-eceived  but  little  attention  until  within  a 
few  years,  and  it  is  only  lately  that  it  has  been  considered  as  a  neurosis. 

Definition Exophthalmic  goitre  is  a  disease  connected  with  vascular 

excitement  and  circulatory  disturbance ;  there  is  not  only  enlargement  of 
the  thyroid  gland,  but  an  excessive  engorgement  of  the  intra-orbital  ves- 
sels, so  that  the  eyeballs  are  pressed  forward,  giving  rise  to  a  hideou- 
deformity. 

Symptoms The  first  symptoms  of  the  disease  are  generally  indi- 
cated by  violent  action  of  the  heart,  and  great  acceleration  in  the  circula- 
tion ;  and  with  this  there  is  hyperaemia  of  the  cerebral  vessels.  Palpitation 
and  pain  over  the  left  side  of  the  chest,  shortness  of  breath,  and  flushing 
of  the  face  are  other  symptoms  of  this  early  stage.  This  early  vascular 
disturbance  is,  perhaps,  the  first  evidence  of  the  disease  noticed  by  the 
patient,  but  the  enlargement  of  the  thyroid  gland  may  have  been  pro- 
gressing for  some  time.  There  may  be  other  early  symptoms  which  ap- 
pear with  increased  growth  of  the  goitre,  and  protrusion  of  the  eyeballs. 
These  are  falling  out  of  the  hair  of  the  eyebrows,  as  well  as  the  eyelashes. 

The  heart's  action  is  violent  throughout  the  disease,  and  the  pulse  may 
beat  from  120  to  140  per  minute ;  while  the  temperature  is  one  or  two 
degrees  higher  than  the  normal  standard.  There  is  nearly  always  a  sys- 
tolic bruit  and  a  carotid  murmur.  The  hand,  when  placed  over  the  goitre, 
may  receive  a  peculiar  sensation,  which  is  produced  by  the  agitation  of 
the  thyroid  by  the  rapidly  circulating  blood  in  the  enlarged  vessels. 

There  is  rarely  any  visual  disturbance,  although  troubles  of  accommo- 
dation are  met  with  ;  and  there  are  no  changes  to  be  observed  in  the  retina. 

Digestion  is  nearly  always  impaired,  and  there  may  be  some  diarrhoea 
or  attacks  of  vomiting;  while  sleep  is  troubled,  and  the  patient  suffers 
greatly  for  want  of  rest. 

1 1  is  ap|K-arance  is  unmistakable.  One  or  both  eyes  are  prominent,  and 
uncovered  by  the  lids  ;  and  the  sclerotic  is  exposed  above  the  cornea  to  a 
great  extent.  The  patient  is  hypermetropic,  and  suffers  considerably  from 
conjunctivitis  produced  by  the  irritation  of  foreign  bodies  which  lodge 
there. 

Dr.  Yeo  reports  two  very  valuable  cases,  which  are  presented  in  admi- 
rable shape  in  a  late  number  of  the  British  Medical  Journal*  In  one  of 
these  (Fig.  48)  there  was  exophthalmosof  the  left  eye  only,  the  goitre  being 
on  the  right  side.  The  second  case  was  thus  described  by  Dr.  Yeo  :  "The 
patient  is  a  young  single  woman,  23  years  of  age,  robust  and  strong-look- 
ing. She  shows  no  signs  of  the  pronounced  cachexia  (phthisical)  so  evi- 
dent in  the  other  patient.  But  she  is  especially  interesting  now,  as  being 

1  March  17,  1877. 


EXOPHTHALMIC    GOITRE. 


413 


also  the  subject  of  unilateral  exophthalmos.  In  her  case  the  right  eye  only 
is  prominent.  There  is  very  little,  if  any,  enlargement  of  the  thyroid,  but 
there  is  constant  palpitation.  The  pulse  has  varied  during  the  time  she 
has  been  under  observation  from  116  to  140.  She  comes  of  a  healthy 

Fi<r.  48. 


Dr.  Yeo's  Case  of  Exophthalmic  Goitre. 

family,  and  has  always  had  good  health  till  lately.  She  first  noticed  the 
prominence  of  the  right. eye  about  a  year  ago.  All  this  time  she  has  been 
feeling  nervous  and  excitable.  She  came  to  King's  College  Hospital  about 
nine  months  ago  complaining  of  pains  in  the  back  of  the  head  and  palpi- 
tation. She  stated,  also,  that  she  suffered  frequently  from  '  bilious  attacks,' 
attacks  of  vomiting  which  would  last  a  whole  day,  after  which  her  throat 
would  get  very  large.  She  complained,  also,  of  frequent  profuse  perspira- 
tions coming  on  twice  and  three  times  a  day,  sometimes  without  any  cause 
and  sometimes  on  the  slightest  exertion.  The  hands  and  feet  are  always 
perspiring,  and  her  hair  is  sometimes  wringing  wet."  She  is  easily 
fatigued,  has  lost  her  appetite,  and  is  much  thinner  than  she  used  to  be. 
She  suffers  much  from  dysmenorrlioea,  and  all  her  symptoms  are  worse  at 


414  CEREBRO-SPINAL    DISEASES. 

her  periods.  She  says  her  throat  was  much  more  enlarged  nine  months 
ago  than  it  is  now. 

There  may  be  double  exophthalmos  or  single,  but  the  double  affection  of 
the  eyes  is  the  rule  in  the  great  proportion  of  cases. 

The  eyeball  may  be  pressed  back,  as  the  vascular  cushion  behind  is 
soft  and  yielding;  and  a  peculiar  thrill  is  to  be  felt.  An  "arcus  senilis" 
lias  repeatedly  been  observed :  by  Bartholovv,1  who  first  called  attention 
to  this  change,  and  by  others,  among  them  Thomas.1  Irritability  of 
temper,  hysteria,  laryngeal  trouble,  and  difficulty  of  breathing  are  symp- 
toms which  are  to  be  noticed,  and  towards  the  end  this  respiratory  em- 
barrassment becomes  quite  distressing. 

The  patient  is  generally  badly  nourished,  and  we  may  have  added  to 
the  symptoms  already  described  many  of  those  of  general  amvinia. 

The  skin  of  the  whole  body  may  sometimes  be  of  a  much  darker  hue 
than  it  is  in  a  condition  of  health,  and  some  discoloration  of  that  covering 
the  forehead  is  often  noticed.  This  discoloration  resembles  a  brown  stain, 
and  it  has  been  spoken  of  as  "bronze  skin"  by  some  writers.  Raynaud3 
has  called  attention  to  the  connection  between  this  stain,  or  vitiligo,  and 
exophthalmic  goitre.  He  gives  "five  cases  of  exophthalmic  goitre,  culled 
from  various  sources,  in  the  course  of  which  patches  of  vitiligo  appeared 
on  various  parts  of  the  body.  Beyond  the  observation  that  vitiligo  is 
more  common  in  men  than  in  women,  except  when  congenital,  that  it 
attacks  by  preference  persons  of  dark  complexion,  that  it  is  sometimes, 
though  rarely,  hereditary,  and  has  a  certain  analogy  to  Addison's  disease, 
viewed  as  an  imperfect  vitiligo,  little  has  been  made  out  with  regard  to 
its  pathology.  Mr.  Hutchinson  has  pointed  out  that  although  no  known 
cachexia  appears  to  set  up  a  predisposition  to  the  affection,  the  symmetry 
of  the  cutaneous  patches  is  suggestive  of  some  pre-existing  general  fault 
of  the  circulatory  or  nervous  systems,  and  is  opposed  to  the  hypothesis  of 
a  parsisitic  origin.  Without  offering  any  explanation  of  the  coexistence 
of  vitiligo  with  exophthalmic  goitre,  Dr.  Raynaud  thinks  that  the  coinci- 
dence should  not  be  allowed  to  pass  unnoticed." 

Roth*  reports  a  case  of  exophthalmic  goitre,  the  patient  being  a  woman 
fifty  years  of  age,  her  menopause  having  taken  place  six  years  before. 
She  became  debilitated,  suffered  from  palpitation  and  sweating  at  night, 
and  afterwards  there  was  gradual  enlargement  of  the  thyroid  gland  and 
protrusion  of  the  eyeballs.  The  pulse  was  120,  and  the  temperature 
normal.  It  was  impossible  for  her  to  close  her  eyelids.  The  exoph- 
thalmos was  greater  on  the  left  side,  and  the  thyroid  was  more  enlarged 
on  the  opjK)site  side. 

Galvanism  was  used,  the  positive  pole  being  placed  on  the  upper  part 
of  the  sternum  and  the  negative  on  the  superior  cervical  ganglion.  On 

1  Chic-ago  Journal  of  Nervous  and  Mental  Discuses,  July,  1875. 

*  Richmond  and  Louisville  Mod.  Joimi.,  Nov.  1876. 

'  Art'hiv.  Gen.,  June,  1875;  and  London  Mcd.  Record,  Sept.  15,  1875. 

4  Wien.  Mod.  Presse,  1875,  No.  30. 


EXOPHTHALMIC    GOITRE.  415 

the  right  side  ten  cells  produced  no  sensation,  but  on  the  left,  six  were 
sufficient  to  produce  burning.  The  current  was  also  passed  through  the 
buck.  The  night-sweats  and  palpitation  diminished,  and  she  grew  stronger. 
At  the  end  of  a  month  she  had  gained  two  pounds  in  weight,  but  the 
reduction  in  size  only  occurred  in  the  left  exophthalmos  and  left  portion 
of  the  thyroid. 

The  connection  of  urticaria  has  been  pointed  out  by  Bulkley,  who 
reports  two  cases  of  the  disease.  One  of  these  is  presented : — 

"Mrs.  — ,  aged  45,  was  delicate  and  sickly  when  a  child.  Was  married 
at  18  years  of  age,  but  separated  from  her  husband  after  4  months;  she 
had  a  miscarriage  at  3  months,  and  has  never  been  completely  well  since. 
She  is  of  full  habit ;  bowels  and  menses  regular ;  tongue  coated ;  pulse  84, 
weak ;  has  had  chronic  rheumatism. 

"  The  history  of  the  Graves'  disease  dates  back  a  number  of  years — at 
least  five  years  previous  to  my  seeing  her.  This  diagnosis  was  made  by 
a  prominent  oculist  whom  she  consulted  about  the  projection  of  her  left 
eye.  She  has  been  treated  much  of  the  time  ineffectually  by  various 
physicians,  remaining  with  each  long  enough  only  to  experience  more  or 
less  benefit,  and  then  changing.  The  eyes  exhibit  clearly  the  peculiar 
appearance  of  patients  with  exophthalmic  goitre,  the  left  one  being  more 
strikingly  prominent,  and  being  of  but  little  service  for  vision,  she  soon 
losing  control  of  it.  The  other.phenomena  of  the  disease  have  been  present 
for  some  years — irregularity  of  the  heart's  action,  and  at  times  severe 
palpitation,  and  enlargement  of  the  thyroid  ;  but  this  is  not  so  very  marked. 

"Five  years  before  coming  to  me  she  experienced  a  severe  nervous 
shock,  and  dates  her  skin  trouble  from  that  period.  She  states  that  she 
has  not  perspired  since.  She  began  then  to  have  'a  fine  rash  and 
redness  all  over  the  body,'  and  itching.  This  continued  about  the  same, 
otf  and  on,  for  four  years,  when,  after  being  weak  and  exhausted,  and 
having  various  hysterical  difficulties,  the  itching  became  more  general, 
and  an  eruption  corresponding  to  that  now  existing  appeared.  Lumps 
would  form  on  the  forehead  and  on  various  parts  of  the  body;  sometimes 
the  face  and  head  would  appear  greatly  swollen. 

••  AVhen  first  seen  she  was  in  a  pitiable  state  of  nervous  anxiety:  the 
itching  of  the  feet  and  toes  and  sometimes  of  other  parts  of  the  body  she 
described  as  agony.  At  the  first  visit  there  was  not  so  much  to  be  seen 
on  the  skin,  but  there  were  a  few  urticarial  blotches  on  various  parts  of 
the  body  and  limbs.  While  under  observation,  however,  she  had  several 
acute  attacks  of  skin  trouble,  all  of  the  same  sort.  On  one  occasion  she 
woke  with  the  upper  lip  greatly  swollen,  and  with  swellings  on  various 
parts  of  the  body.  On  the  following  day,  when  seen,  the  whole  face  was 
swollen  and  puffy;  on  the  middle  of  the  forehead  there  was  a  large  eryihe- 
matous  lump,  also  one  beneath  the  right  eye,  and  smaller  ones  about  the 
face.  The  hands  were  swollen;  on  the  right  hand,  near  the  little  iin.ir.-r, 
there  was  an  erythematous  patch,  somewhat  swollen  and  with  two  small 
vesicles  on  it.  *  There  were  also  various  erythematous  and  urticarial 
blotches  about  both  hands  and  wrists ;  and  on  the  back  of  the  left  hand, 
near  the  thumb,  there  was  a  red  spot  with  the  skin  broken,  as  if  tin-  scat 
of  a  former  vesicle.  The  whole  surface  of  the  skin  burned  as  if  scalded 
or  scratched;  there  was  no  pain  on  deep  pressure.  On  another  occasion, 
a  dav  or  two  after  there  had  been,  according  to  her  statement,  numerous 


416  CEREBRO-SPINAL    DISEASES. 

swellings  on  various  parts  of  the  body,  the  remains  of  several  were  visible 
on  the  right  cheek,  and  on  the  arms  there  were  num. -rous  >iain>.  some  of 
them  quite  dark,  as  if  the  parts  had  been  bruised — the  'remains  of  the 
lumps;  the  hands  and  arms  were  manifestly  swollen,  and  there  wnv 
urticarial  wheals  on  the  liaibs  and  body." 

The  following  case  is  one  of  unilateral  thyroid  enlargement,  with 
double  exophthalmos : — 

Mrs.  L.  B.,  28,  U.  S. ;  milliner.  Was  always  well  until  eight  years 
ago,  when  her  present  difficulty  began.  She  was  then  living  in  New 
York,  and  actively  employed.  At  this  time  she  noticed  the  growth  of  a 
goitre  upon  the  right  side  of  the  neck,  which  pulsated  violently  when  she 
was  excited  or  over-fatigued.  She  then  flushed  easily,  and  often  had 
headaches,  which  were  quite  intense.  These  she  has  now,  and  her  pain 
is  of  the  congestive  variety,  and  diffused.  She  presented  herself  at  the 
out-patient  department  of  the  New  York  Hospital,  complaining  of  a  pain 
just  beneath  the  border  of  the  last  rib  on  the  left  side,  which  was  quite  con- 
stant, but  not  increased  by  pressure,  or  by  taking  a  long  breath,  or  after 
eating.  The  pain  was  most  severe  in  the  morning,  and  seemed  to  move 
off  towards  night.  Her  heart  seemed  healthy,  as  far  as  valvular  lesions 
were  concerned,  for  no  abnormal  murmur  was  present ;  but  there  was 
great  rapidity  of  action,  the  pulse-beats  varying  from  106-120  per  minute. 
The  pulse  was  also  quite  bounding,  and  full.  The  carotids  pulsated  quite 
strongly,  and  there  was  a  very  marked  venous  thrill  perceptible  in  the 
jugulars.  Upon  the  right  side  of  the  neck,  just  above  the  sterno-clavicu- 
lar  articulation,  and  extending  laterally,  there  was  a  tumor  measuring 
2^  inches  in  length,  and  about  2  inches  in  breadth.  The  marked  pulsa- 
tion of  this  growth  led  Dr.  Slaughter  and  myself  to  suppose  at  first  that 
it  was  an  aneurism,  but  we  were  unable  to  reduce  it  by  pressure,  or  to 
diminish  its  size  by  compression  of  the  carotid ;  and  there  was  no  history 
of  injury.  The  peculiar  movement  was  due  to  the  pulsation  of  the  carotid 
UJKUI  which  it  rested  above,  and  laterally  passed  the  right  jugular  vein, 
which  was  also  agitated  by  the  transmitted  pulsation  of  the  carotid. 
When  the  hand  was  placed  upon  the  enlargement  there  was  perceived  an 
nndulatory  or  "  purring"  movement.  No  bruit  was  heard  with  the  stetho- 
scope, but  the  tracheal  sound  was  readily  perceived.  This  growth  under- 
went variation  in  its  size.  Cold  weather  seemed  to  influence  it  in  this 
way,  and  stimulants,  or  other  agencies  which  increased  the  blood  pressure, 
materially  modified  its  sixe.  The  face  was  puffed,  bloated,  and  red,  and 
the  eyeballs  were  somewhat  prominent,  while  the  pupils  were  dilated,  and 
the  iris  rather  sluggish.  She  was  not  hypermetropic,  and  there  were  no 
other  defects  noticed.  By  steady  pressure  I  was  enabled  to  perceive  the 
"  cushion  feeling"  alluded  to  by  medical  writers  who  have  observed  this 
disease.  Her  companions  twitted  her  in  regard  to  her  fixed  stare,  which 
resulted  from  the  exophthalmos.  Her  ankles  and  feet  were  oedematous, 
and  pitted  deeply  on  pressure.  Her  urinary  organs  seemed  to  be  in  order, 
and  there  were  no  indications  of  renal  disease.  She  has  noticed  at  times 
patches  of  rusty  discoloration  which  appeared  about  her  neck  and  upon 
the  left  side  of  her  face.  These  lasted  for  several  days,  and  then  faded 
away.  She  has  had  several  minor  symptoms,  such  as  nose-bleed,  which 
occurs  even  now,  every  two  or  three  weeks.  Her  menses  are  scant,  but 
there  is  apparently  no  interior  disease.  Her  digestion  is  feeble,  and  she 
is  slightly  constipated.  R — Ext.  ergotze  fl.  $j,  t.  i.  d. 


EXOPHTHALMIC    GOITRE.  417 

Causes — The  disease  is  one  of  middle  age,  and  there  are  about  twice 
as  many  females  as  males  affected.  It  is  connected,  in  some  cases,  with 
metrorrhagia,  or  hoemorrhoidal  bleeding,  or  in  others  with  heart  disease. 

Examples  of  traumatic  origin  have  been  noted  by  Begbie1  and  Von 
Graef'e,9  and  others  have  been  apparently  of  idiopathic  origin.  The  case 
of  the  first  followed  head  injury. 

Morbid  Anatomy  and  Pathology — The  observations  of  those 
who  have  made  autopsies  differ  greatly.  Morel  Mackenzie  found  soften- 
ing of  the  corpora  quadrigemina  and  the  posterior  part  of  the  medulla. 
The  heart  was  not  much  affected,  there  being  only  slight  atheromatous 
deposits  on  the  mitral  and  aortic  valves,  with  thinness.  Other  observers 
have  found  hypertrophy  of  the  heart  and  insufficiency  of  its  valves,  but 
in  other  cases  there  were  no  heart  lesions  whatever.  The  thyroid  gland 
has  been  found  to  contain  enlarged  vessels,  and  the  orbits  an  increased 
quantity  of  fatty  tissue.  In  one  of  Begbie's  cases  there  was  sinking  of 
the  eyeballs  in  the  orbital  cavities  after  death. 

Much  discussion  has  taken  place  in  regard  to  the  pathology  of  the 
affection,  but  recent  investigations  point  to  the  nervous  origin  of  the  dis- 
ease. The  cervical  sympathetic  has  been  found  to  be  altered,  and 
numerous  instances  of  the  change  have  been  brought  forwrard  by  Reck- 
linghausen,3  Trousseau,*  Archibald,5  and  others.  Notwithstanding  this 
explanation  (the  sympathetic  origin),  others  contend  that  it  is  a  disease 
of  the  brain ;  and  still  another  theory  is  accepted  by  those  who  consider 
it  a  cardiac  disease  per  se.  The  nervous  origin  seems  to  me  to  be  that 
which  is  most  acceptable.  Not  only  does  the  use  of  galvanic  treatment, 
which  cures  the  disease,  suggest  this  neurotic  character  of  the  affection, 
but  the  hysterical  phenomena  mentioned  by  Basedow,  and  noticed  fre- 
quently by  others,  are  certainly  significant. 

We  may,  I  think,  consider  the  disease  to  be  dependent  upon  an  affection 
of  both  the  sympathetic  and  spinal  accessory  nerves.  The  condition  of 
the  vessels  of  the  thyroid  gland  and  those  of  the  orbit,  the  flushing  of  the 
face,  and  general  disturbance  of  digestion,  are  probably  due  to  the  altered 
function  of  the  first-mentioned  nerve,  and  the  heart  excitement  is  a  con- 
sequence of  deficient  innervation  of  the  accessories. 

Diagnosis There  need  be  no  mistake  made  in  the  diagnosis  of  this 

affection  from  simple  goitre,  and  after  this  is  accomplished  there  is 
nothing  else  suggested.  One  inspection  of  the  enlarged  thyroid,  and  the 
protruding  eyeballs,  and  the  detection  of  the  vascular  excitement,  are 
sufficient  to  enable  us  to  say  that  the  case  is  one  of  exophthalmic  goitre. 

Prognosis A  cure  is  recorded  by  Cheadle ;  another  by  Mackenzie,6 

1  St.  George's  Hospital  Reports,  vol.  iv.,  1869. 

2  Arclu'v  fur  Ophthal.,  1857. 

3  Deutsche  Klinik,  1863. 

4  Trousseau  and  Peter,  Gaz.  Hebdom.,  1864. 

5  Med.  Times  and  Gaz.,  1865.  6  Op.  cit. 
27 


418  CEREBRO-SPINAL    DISEASES. 

who  also  reported  a  death.  Bartholow1  has  cured  three  patients ;  Ham- 
mond* tour,  and  reports  one  death.  Dr.  J.  P.  Thomas,8  of  Kentucky, 
details  a  very  interesting  case  which  ended  fatally  in  five  years.  Very 
little  can  be  said  in  regard  to  the  diameter  of  the  disease,  but  it  has  been 
cured  in  certain  instances  in  a  year  or  two.  It  may  last  for  several  years, 
however,  and  is  essentially  a  chronic  affection.  Trousseau,  Charcot,  and 
Corlieu4  report  cures,  in  which  pregnancy,  uterine  hemorrhage,  or  some 
such  complications  occurred  during  the  disease,  influencing  its  disappear- 
ance. 

Treatment — Galvanism,  it  seems,  has  succeeded  admirably,  and 
Uartholow  has  cured  three  cases  by  this  agent.  Chalybeate  preparations, 
digitalis,  ergot,  and  cod-liver  oil  are  all  excellent  remedies  (FF.  G,  8,  '2  1 . 
4(1).  If  galvanism  be  nsed,  we  should  bring  the  sympathetic  nerve  under 
its  influence  by  placing  one  pole  (the  positive)  at  the  angle  of  the  IOVMT 
jaw,  and  apply  the  negative  over  the  epigastrium. 

1  Op.  cit.  2  Op.  cit.,  p.  797. 

3  Richmond  and  Louisville  Med.  Journal,  1877. 

4  Rep.  by  Jaccoud,  vol.  i.,  p.  672,  2d  edition. 


NEURALGIA.  419 


CHAPTER    XY. 

DISEASES  OF  THE  PERIPHERAL  NERVES. 
NEURALGIA. 

Synonyms — (See  special  varieties.) 

Definition — Neuralgia  may  be  defined  as  "  a  disease  of  the  nervous 
system,  manifesting  itself  by  pains  which  in  the  majority  of  cases  are 
unilateral,  and  which  appear  to  follow  accurately  the  course  of  particular 
nerves,  and  ramify  sometimes  into  a  few,  sometimes  into  all,  the  terminal 
branches  of  those  nerves."1 

Neuralgia  is  essentially  the  result  of  lowered  vitality,  and  is  never  a 
consequence  of  any  sthenic  condition.  This  is  proved  by  the  circum- 
stances under  which  it  occurs ;  it  taking  its  origin  from  general  debility, 
rheumatism,  syphilis,  or  malaria,  or  some  other  disease  which  produces  a 
cachexia.  Anstie  very  justly  considers  that  it  is  the  first  expression  of  a 
condition  which  later  on  becomes  paralysis — one  being  a  partial  disturb- 
ance, or  cutting  off  of  the  nervous  supply ;  and  the  other  a  complete  inter- 
ruption of  the  nervous  force ;  and  it  is  a  familiar  fact  that  neuralgia  very 
often  precedes  loss  of  power  in  parts  supplied  by  an  affected  nerve. 

Neuralgia  is,  then,  a  disease  in  which  pain  is  the  prominent  symptom, 
and  with  which  circulatory,  trophic,  and  motorial  disturbances  may  be  con- 
nected. 

Pain — Neuralgic  pain  is  quite  distinct  from  that  of  any  other  disease. 
It  is  not  at  all  like  that  of  neuritis,  which  is  constant  and  aggravated  by 
pressure,  but  it  is  paroxysmal,  and  is  characterized  by  a  stage  of  increas- 
ing intensity  and  rapid  recurrence,  and  by  a  second  stage  of  "  wearing 
out"  or  subsidence.  It  appears  suddenly,  disappears,  and  returns,  being 
broken  by  a  period  of  rest.  These  breaks  or  intervals  of  remission  be- 
come shorter  as  the  attack  increases  in  severity,  until  the  pain  seems  almost 
continuous.  When  the  climax  is  reached,  the  intervals  grow  in  length, 
and  the  pain  diminishes  in  severity,  and  finally  subsides.  Repeated  neu- 
ralgic attacks  leave  the  nerve  in  a  hyperoesthetic  condition,  so  that  at  par- 
ticular points  it  is  tender  and  sensitive  to  pressure. 

These  foci  of  exalted  sensation  have  been  called  by  Valliex2  "  les  points 
douleureux,"  and  correspond  to  the  points  of  emergence  of  the  nerve  from 
its  foramen,  or  at  u  point  when  it  passes  from  a  deep  to  a  superficial  course. 
The  terminal  ends  of  nerves  are  much  more  often  the  seat  of  this  tender- 
ness than  any  other  part.  The  external  ramifications  of  the  supra-orbital 
branch  of  the  fifth  or  the  small  filaments  of  other  nerves — the  ulnar  and 


1  Anstie,  Neuralgia,  etc.,  p.  14.  2  Traite  des  Xeuralgies,  Paris,  1841. 


420  DISEASES    OF    THE    PERIPHERAL    NERVES. 

radial  for  instance — are  not  rarely  painful  to  pressure.  These  painful 
points  are  met  with  very  frequently  in  cases  of  facial  neuralgia.  A  gcn- 
tleinan  who  consulted  me  some  time  ago  presented  this  indication  of  facial 
neuralgia,  there  being  several  hyper-aesthetic  spots  in  the  roof  of  his  mouth, 
and  his  gums  on  one  side  were  exquisitely  tender. 

Circulatory  disturbances,  of  a  quite  marked  character,  are  pronounced 
features  of  the  neuralgic  attack.  The  pulse  at  first  is  irritable,  small,  and 
quite  rapid.  A  species  of  fluttering  palpitation  is  also  present,  and  the 
surface  is  pale  and  cool.  In  the  later  stages  of  the  attack,  after  the  pain 
has  grown  decided,  the  face  becomes  flushed ;  the  pulse  soft,  full,  and 
quite  bounding ;  and  the  eyes  may  be  suffused  and  bloodshot,  should  the 
attack  be  one  of  facial  neuralgia. 

During  this  stage,  and  after  the  subsidence  of  the  pain,  the  patient  may 
sweat  profusely. 

Trophic  Disturbances — These  may  be  connected  with  the  acute  pa- 
roxysms, or  may  result  from  repeated  attacks.  Among  the  former  may  be 
pemphigus,  and  herpetic  and  bullous  eruptions ;  and  among  the  latter,  loss 
of  teeth  or  hair,  or  alteration  in  the  coloring  matter  of  the  hair,  atrophy 
of  muscular  tissue,  and  various  cutaneous  changes.  Charcot  and  AYeir 
Mitchell,  as  well  as  various  writers  upon  dermatology,  have  called  atten- 
tion to  the  connection  of  aggravated  neuralgic  pain,  with  various  cutaneous 
diseases.  The  most  striking  of  these  neurotic  skin  diseases  is  herpes 
zoster,  in  which  are  eruptions  of  a  vesicular  character,  a  cluster  of  patches 
being  found  here  and  there  along  the  course  of  the  affected  nerve.  The 
pain  precedes  the  appearance  of  the  eruption,  and  may  continue  during  its 
existence,  and  for  some  time  after,  or  there  may  remain  a  pruritus,  limited 
to  the  parts  which  have  been  the  seat  of  eruption.  The  neurotic  character 
of  this  complication  may  be  proved  by  its  very  rapid  disappearance  after 
galvanization  of  the  affected  nerves,  or  administration  of  large  doses  of 
quinine.1  The  other  trophic  alterations,  which  are  secondary,  will  be  con- 
sidered at  a  later  period. 

Motility — Connected  with  some  forms  of  neuralgia  are  certain  conditions 
of  spusm.  In  a  form  of  facial  neuralgia  which  has  been  known  as  tic 
epileptiform  or  tic  douloureux,  tonic  spasm  of  the  eyelid  or  of  the  masseter 
muscles  is  present  as  a  decided  symptom.  Convulsive  movements  of  the 
legs,  due  to  spasms  of  the  flexors,  have  also  been  observed  in  sciatica  by 
Anstie;  but  in  cases  in  which  I  have  noticed  this  symptom,  it  seemed 
rather  a  result  of  excessive  pain,  and  an  effort  upon  the  part  of  the  patient 
to  relax  the  pressure  upon  the  affected  nerve.  Local  spasms  are  quite 
common  ;  and  the  muscles  of  the  face,  of  the  trunk  or  limbs,  and  the 
vomiting  of  sick  headache,  are  varieties  of  spasmodic  action  which  may 
be  cited  as  examples  of  this  kind.  In  a  case  lately  under  treatment,  I 
have  been  reminded  of  a  condition  which  I  have  several  times  observed 
— a  species  of  heart  pain  resembling  that  of  angina  pectoris,  and  connected 
with  facial  neuralgia.  With  this  pain  there  would  be  spasmodic  contraction 


A  form  of  skin  disease  lately  denominated  pompholyx  by  Dr.  A.  R.  Robin- 
son, of  New  York,  is  an  example  of  a  neurosis  of  this  kind. 


NEURALGIA.  421 

of  the  muscles  of  the  thorax.  Mitchell1  "has  encountered  from  time  to 
time  certain  forms  of  neuralgia,  accompanied  by  muscular  spasms  and 
extravasations  of  blood  in  the  affected  part.  He  relates  three  cases,  all 
occurring  in  females,  and  explains  the  circumscribed  hemorrhages  by 
nutritive  changes  in  the  walls  of  the  vessels,  occasioned  by  conditions  of 
the  nervous  system  analogous  to  atrophic  changes  in  the  skin  and  nails 
in  nervous  diseases." 

Valliex  has  divided  the  neuralgias  into  the  superficial  and  the  visceral, 
and  classifies  them  as  follows : 

A.  Superficial. 

1.  Neuralgia  of  the  fifth  nerve  (trifacial  or  trigeminal  neuralgia). 

2.  Cervico-occipital. 

3.  Cervico-brachial. 

4.  Intercostal. 

5.  Lumbo-abdominal. 

6.  Crural. 

7.  Sciatica. 

B.   Visceral. 

1.  Uterine  or  ovarian  neuralgia. 

2.  Neuralgia  of  the  urethra. 

3.  "  «      bladder. 

4.  "  "      rectum. 

5.  "  "      testis. 

6.  Hepatic  neuralgia. 

7.  Neuralgia  of  the  heart. 

8.  "  "      stomach. 

9.  Laryngeal  and  pharyngeal  neuralgia. 

Among  the  first  group  the  most  important  is  neuralgia  of  the  fifth  nerve, 
which  may  also  ex.ist  with  a  motor  complication,  as  tic  epileptiform,  or 
with  gastric  complications,  as  migraine  or  "  sick  headache.' 

FACIAL  NEURALGIA. 

Synonyms — Face-ache  ;  FothergilFs  face-ache  ;  Prosopalgia  ;  Tri- 
geminal neuralgia;  Tic  douloureux;  Migraine;  Sick  headache. 

The  supra-orbital  branch  may  be  alone  affected,  and  the  pain  confined 
to  the  brow  and  top  of  the  head,  or  it  may  be  quite  generally  diffused 
over  the  face  and  head,  the  three  branches  being  involved.  The  first 
division  of  the  nerves  is,  however,  the  most  common  seat  of  neuralgia; 
but  it  is  not  unusual  for  an  attack  to  begin  above,  and  finally  extend  to 
all  of  the  divisions  of  the  nerve  on  one  side. 

Migraine,  or  "  sick  headache,"  presents  the  following  features :  The 
attack  may  be  preceded  by  some  chilliness,  pallor,  and  uneasiness,  and  is 

1   American  Journ.  ofMed.  Sei.,  Iviii.  16. 


422  DISEASES    OF    TUB    PERIPHERAL    NERVES. 

ushered  in  by  a  twinge  of  pain,  which  begins  just  above  the  eye  on  one 
side,  and  radiates  over  the  head.  The  pain  is  often  erroneously  referred 
by  the  patient  to  both  sides  of  the  head,  when,  in  reality,  but  one-half  is 
affected.  Deep-seated  orbital  pain,  photophobia,  hcmiopia  and  nausea, 
with  an  irritable,  thready  pulse,  and  increase  of  pain,  immediately  usher 
in  the  attack,  which  rapidly  increases  in  severity;  the  pulse  after  a  while 
losing  its  asthenic  character,  and  becoming  full  and  bounding.  The 
patient's  face  becomes  flushed,  and  his  skin  red  and  sweaty,  and  in  rare 
cases  the  sweating  is  confined  to  one  side  of  the  face.  The  paroxysms  of 
pain,  which  at  first  were  separated  by  intervals  of  relief,  next  become 
almost  continuous,  but  after  a  time,  during  which  the  patient  may  feel 
like  vomiting,  they  become  less  severe,  and  finally,  after  his  stomach  has 
been  emptied,  may  disappear  altogether.  The  features  of  an  attack  of  this 
kind  are  too  familiar  to  need  elaboration.  The  following  case  will  serve  as 
an  illustration  : — 

Mrs.  G.  is  a  delicate,  hysterical  woman,  who  devotes  most  of  her  time 
to  duties  of  society.  Her  domestic  affairs  are  worrying,  and  the  constant 
excitement  of  entertaining,  late  hours,  and  the  management  of  several  un- 
ruly children,  have  so  worn  upon  her  that  now,  at  the  end  of  the  winter, 
she  is  anannic,  "  run  down,"  and  suffers  from  want  of  appetite,  insomnia, 
and  general  debility.  About  twice  a  week,  at  irregular  times,  she  suffers 
in  the  beginning  from  light  pains,  radiating  from  the  right  eye,  and  over 
the  head,  which  become  quite  severe,  and  increase  during  the  next  hour 
or  two.  She  usually  becomes  cold,  and  bundles  herself  up  in  shawls  and 
wraps.  Her  eyelids  feel  heavy,  and  the  "  skin  covering"  her  "  face  feels 
as  if  it  were  drawn  tightly."  She  is  nervous  and  irritable,  and  cannot 
bear  the  presence  of  her  children,  and  is  sometimes  so  depressed  that  she 
bursts  into  tears.  She  has  a  vague  dread  of  some  trouble,  the  character  of 
which  she  does  not  know.  The  pain  increases  in  severity,  and  becomes 
almost  unbearable.  Her  eyes  are  hot,  and  "  it  seems  as  if  a  peg  was  being 
driven  in  from  behind."  Her  face  becomes  very  hot,  and  her  temporal 
vessels  throb.  The  slightest  step  she  may  take  in  walking  so  jars  her  head 
that  it  gives  rise  to  intense  pain.  She  "  feels  as  if"  her  "  head  would  split 
open."  She  cannot  look  out  of  the  window,  but  lies  upon  her  bed,  and 
buries  her  face  in  the  pillows.  Nothing  seems  to  relieve  her.  She  may 
lie  so  for  hours,  panting  for  breath,  and  pressing  her  aching  head.  After 
a  variable  time,  sometimes  two  hours,  sometimes  a  day,  the  pain  is  dimin- 
ished somewhat,  and  she  becomes  nauseated ;  not  because  food  lies  undi- 
gested, for  she  has  taken  none  for  some  time,  but  the  vomiting  is  of  a 
purely  cerebral  character.  She  attempts  to  vomit,  but  cannot  bring  up 
anything.  The  effort  at  retching  jars  her  body,  and  increases  the  pain. 
After  this  state  of  affiiirs  has  lasted  for  some  little  time,  she  becomes 
exhausted,  and  falls  back  upon  the  bed,  sweating  profusely.  The  pain 
grows  very  much  less  severe,  is  dull  and  throbbing,  and  finally  she  sinks 
into  a  deep  sleep,  from  which  she  awakens  somewhat  relieved. 

The  variations  in  pain  and  circumstances  which  give  rise  to  the  disease 
have  led  different  observers  to  apply  such  names  as  "  rheumatic,"  "  hys- 
terical," "  sympathetic,"  "  organic,"  "  syphilitic,"  and  "  clavus."  These 
terms  have  little  value,  and  it  seems  that  a  nomenclature  based  upon  the 
anatomical  situation  of  the  neuralgia  is  all  that  is  needed,  and  it  certainly 


NEURALGIA.  423 

would  do  away  with  much  confusion.  Facial  neuralgia,  unless  it  be  due 
to  temporary  exciting  causes  which  may  be  readily  removed,  is  rather  an 
obstinate  affection.  It  may  take  a  periodic  character,  especially  if  it  be 
connected  with  malaria ;  or  it  may  be  more  intense  at  night,  should  it  be 
of  syphilitic  origin.  The  true  attack  rarely  lasts  beyond  a  few  hours,  but 
attacks  (especially  of  tic-douloureux)  may  be  so  frequent  as  to  become 
almost  continuous.  The  tendency  is,  I  think,  for  the  disease  to  become 
firmly  rooted,  and  to  increase  in  severity.  If  there  be  a  rheumatic,  mala- 
rial, or  anaemic  form,  there  is  no  reason  why  the  disease  should  not  subside 
when  these  morbid  conditions  are  removed.  As  to  clavus,  in  which  the 
pain  is  compared  to  that  which  would  probably  follow  the  driving  of  nails 
through  the  skull,  it  may  be  said  that  this  is  an  hysterical  condition,  and 
the  patients'  descriptions  are  based  upon  the  workings  of  a  disordered  im- 
agination. 

There  are  very  few  cases  of  facial  neuralgia  in  which  all  the  branches 
may  not  be  involved  at  some  time  or  other.  If  the  neuralgia  be  confined 
more  particularly  to  the  first  and  second  branches  of  the  fifth,  the  temples 
and  forehead,  upper  eyelid,  root  of  the  nose,  and  the  orbits  will  be  the 
points  at  Avliich  the  pain  will  be  the  most  severe.  Toothache,  above  and 
below,  will  indicate  involvement  of  the  middle  and  lower  branches,  and  if 
the  lingualis  be  affected,  which  it  quite  rarely  is,  the  tongue  will  be  the 
seat  of  the  violent  pain.  The  painful  points  are  to  be  found  principally 
over  the  supra-orbital  notch,  the  infra-orbital  foramen,  the  "  malar  point," 
or  in  the  roof  of  the  mouth,  over  the  mental  foramen,  and  in  front  of  the 
ear.  During  the  attack  it  is  not  uncommon  to  find  hypersecretion  of  sa- 
liva, that  fluid  passing  from  the  angle  of  the  mouth  in  great  quantity,  and 
when  the  supra-orbital  and  infra-orbital  branches  are  involved  there  may 
be  a  corresponding  profuse  lachrymation.1  Erbs  has  called  attention  to 
the  occasional  increase  of  secretion  from  the  nasal  mucous  membrane. 
This  has  been  referred  by  Vulpian  to  irritation  of  one  of  the  spheno-palatine 
ganglia.  The  patient  is  nearly  always  excited  and  irritable,  and  if  the 
paroxysms  be  of  frequent  occurrence  he  suffers  from  insomnia,  and  is  en- 
tirely unfitted  for  his  daily  occupations.  It  must  not  be  supposed  that  the 
vomiting  of  migraine  has  any  direct  connection  with  the  condition  of 
digestion.  The  attacks  are,  however,  aggravated  by  the  presence  of  un- 
digested food  in  the  stomach. 

The  deep  neuralgias  of  this  nerve  are  very  obstinate,  and  often  beyond 
the  reach  of  any  treatment.  This  is  notably  the  case  when  the  superior 
maxillary  or  its  orbital  branches  are  affected.  The  ocular  symptoms  are 
then  of  the  most  formidable  description,  and  life  to  the  patient  is  a  burden 
indeed. 

The  following  is  one  of  the  most  inveterate  cases  of  neuralgia  of  this 
kind  I  have  ever  observed.  The  patient's  trouble  began  in  1863,  while 
at  school,  and  then  affected  the  superior  maxillary  and  infra-orbital 


1  Sometimes  there  is  spasmodic  closure  of  the  orifice  of  the  lachrymal  dut't. 

2  Ziemssen's  Encyclopaedia,  vol.  ii. 


424  DISEASES    OF    THE    PERIPHERAL    NERVES. 

branches  of  the  fifth  nerve.  His  sufferings  were  intense,  and  after  trying 
almost  all  forms  of  treatment,  and  consulting  medical  men  in  Europe  and 
in  this  country,  he  consented  to  subject  himself  to  an  operation  for  CXMT- 
tion.  The  history  he  brings,  which  was  taken  by  the  house  surgeon,  Dr. 
Peale,  of  Chicago,  details  the  surgical  procedures  undertaken. 

"Patient  has  for  a  long  time  suffered  from  neuralgia  of  supra-  and  iiil'ni- 
orbital  nerves,  and  the  superior  trochlear  nerve.  Prior  to  this  he  had  a 
closure  of  the  lachrymal  ducts  of  both  sides.  He  had  been  in  Central 
America,  where  he  was  exposed  to  severe  forms  of  malaria.  About  two 
years  ago,  Dr.  Strawbridge,  of  Philadelphia,  cut  oft'  the  supra-orbital 
nerves  at  their  point  of  exit  from  the  supra-orbital  foramen.  In  'either 
eye  there  is  loss  of  accommodation,  and  a  high  degree  of  hypermetropia. 
Prof.  Holmes,  of  this  city,  after  an  ophthalmoscopic  examination,  told 
him  that  the  veins  of  the  retina  were  diminished  in  size. 

He  still  suffers  intensely  with  the  infra-orbital  nerves,  and  comes  in  de- 
siring to  have  them  excised.  He  receives  3^  grs.  morphia,  hypodermically, 
each  day. 

Dec.  18,  1876.  An  incision  made  downward  from  the  location  of  each 
infra-orbital  foramen  to  the  length  of  one  inch  through  the  tissues  of  the 
cheek,  the  nerves  raised  on  a  blunt  hook,  stretched  well  out,  and  chipped 
off  at  their  point  of  exit.  Ether  used  as  the  anaesthetic,  collodion  and  silk 
sutures  to  approximate  the  edges  of  the  incision. 

19^/j.  Patient  suffering  from  intense  pain  referred  to  outer  edge  of  right 
lower  eyelid. 

23d.  Considerable  cellular  inflammation  of  right  side  of  neck  and  face. 

2(>th.  Considerable  discharge  of  pus  from  incision  on  right  side  of  face ; 
swelling  very  much  diminished. 

2'.)th.  Discharge  of  pus  from  both  incisions  has  now  about  ceased  ;  con- 
siderable cellular  inflammation  of  right  side  of  face  in  parotid  region.  He 
claims  he  has  still  the  neuralgic  pain,  but  deeper  in  the  infra-orbital  re- 
gion. 

31st.  Considerable  swelling  and  a  great  deal  of  tenderness  on  either 
side  of  the  neck  below  the  jaw.  Patient  cannot  move  the  jaw. 

Jan.  5,  1877.  Face  continues  swollen,  and  very  painful ;  thinks  he  still 
has  the  old  neuralgic  pain  on  right  side.  Quantity  of  opiates  in  24  hours 
considerably  diminished. 

'2'.)th.  Patient,  again  placed  under  the  influence  of  ether.  An  incision 
made  on  the  right  side  in  the  site  of  the  old  one,  and  the  nerve  raised  on 
a  blunt  hook  and  divided.  Following  the  operation  the  pain  became 
severe,  and  the  hemorrhage  excessive.  For  a  couple  of  hours  all  sorts  of 
efforts  were  made  to  stop  it,  and  finally  we  were  obliged  to  resort  to  ol. 
terebinth,  and  ferri  persulph.  These,  with  compresses  bound  on  as  best 
we  could,  checked  it  so  that  it  only  oozed.  A  large  quantity  of  anodyne 
was  required  to  allay -pain. 

30th.  There  has  been  no  further  hemorrhage.     Morph.  pro  re  nata. 

Feb.  2.  All  dressing  removed  without  hemorrhage ;  wound  left  open 
and  suppurating  ;  dressed  with  carbolic  acid  ;  pain  controlled  with  morph. 

4t/i.  Complains  of  pain  in  right  temple.  P.  M.  Severe  headache ; 
wound  dressed  twice  a  day. 

\\th.  Patient  had  been  doing  well  until  yesterday.  There  was  a  hem- 
orrhage from  the  wound  in  the  morning,  controlled  by  syringing  with 
cold  water.  Last  night  another  very  severe  hemorrhage  ;  used  dry  ferri 


NEURALGIA.  425 

persulph.  Has  had  three  hypodermic  injections  of  f  gr.  morph.  each,  daily. 
Ordered  iodoform  to  be  sprinkled  in  wound. 

March  27.  At  3  P.  M.  patient  was  etherized,  and  Prof.  Bogue  pro- 
ceeded to  resect  the  orbital  branch  of  the  superior  maxillary  nerve.  A 
circular  flap  begun  in  the  old  cicatrix  on  the  right  side,  and  curving 
backwards,  laid  bare  the  molar  bone.  An  opening  was  then  made  through 
its  quadrilateral  surface  with  aTtrephine  into  the  antrum  ;  the  floor  of  the 
orbit  was  then  gouged  away  and  the  nerve  hooked  up  and  ruptured. 
There  was,  following  this,  hemorrhage.  A  plug  of  sponge  was  then 
stuffed  into  the  antrum  and  left.  In  the  evening  there  was  a  severe 
hemorrhage  from  the  nostrils  and  mouth ;  the  nostrils  were  plugged. 
Later  in  the  evening  the  sponge  and  plug  were  removed ;  the  antrum 
washed  out ;  there  was  a  brisk  hemorrhage.  Monsel's  styptic  was  freely 
injected  ;  finally  the  antrum  was  again  plugged  with  sponge  soaked  in  the 
same  solution.  The  eyeball  was  noticed  to  project  considerably  more 
than  its  fellow,  but  the  sight  was  not  much  impaired.  Patient  has  had, 
till  the  present  time  (10  A.  M.),  morph.  gr.  iij,  by  hypodermic  injection. 
This  morning  complains  of  great  pain  in  the  eye  and  upper  jaw.  Plugs 
not  removed.  Ordered  whiskey  and  morph.  to  allay  pain.  P.  M.  Pulse, 
76  ;  temp.  103°. 

30th}  A.  M.  Pulse,  72  ;  temp.  100°. 

On  yesterday  evening  the  sponge  plugs  removed  from  the  wound  ;  no 
hemorrhage  occurred  ;  they  were  not  replaced  ;  water-dressing  continued 
through  the  night.  This  morning  the  wound  is  suppurating  slightly ; 
face  not  swollen  quite  so  badly.  Patient  has  had  one  grain  morph.  by 
hypodermic  injection  every  4  hours  for  the  past  48  hours.  Water-dress- 
ing continued.  Patient  still  complains  of  great  pain  in  the  right  eye ; 
swelling  is  considerable ;  eye  closed,  with  conjunctiva  protruding  from 
between  the  lids.  A  pledget  of  lint  saturated  with  alcohol  was  laid  in 
wound,  and  water-dressing  continued. 

April  1.  Is  feeling  better;  wound  is  suppurating  considerably;  is  not 
swollen  so  badly  ;  plugged  with  lint  saturated  with  alcohol,  and  the  cold 
compresses  continued. 

3d.  The  surface  of  the  wound  is  covered  with  healthy  granulations. 
The  eye  very  much  improved  ;  can  open  it ;  can  distinguish  objects  at  some 
distance. 

4th.  The  patient's  condition  rapidly  improved. 

6th.  Cavity  granulating  finely ;  appetite  good ;  everything  appears  fa- 
vorable at  this  time." 

The  patient  came  to  New  York  and  consulted  me  October  17,  1877. 
In  spite  of  all  the  surgical  operations  the  pain  is  as  severe  as  it  ever  was, 
the  focus  of  intensity  being  evidently  the  orbital  branch.  The  eve  is 
without  sight,  but  no  retinal  changes  can  be  discovered,  except  paleness 
at  the  fundus.  The  conjunctiva  is  injected,  and  the  eye  is  suffused.  I 
gave  him  two  hypodermic  injections  of  morphia,  of  one  grain  each,  within 
an  hour,  but  none  of  the  physiological  effects  followed,  and  the  pain  re- 
mained unabated.  Nothing  remains  to  be  done  but  deep  section  of  the 
nerve. 

A  formidable  neuralgia  is  that  connected  with  spasm  of  the  facial 
muscles,  which  has  received  the  name  of  tic  douloureux  or  tic  epilep- 
tiform.  The  former  term  is  that  applied  by  Benedikt,  and  has  been 


420  DISEASES    OF    THE    PERIPHERAL    NERVES. 

generally  accepted  by  most  writers  to  express  the  violent  and  sudden 
twinges  of  pain  which  are  accompanied  by  very  forcible  spasms  of  the 
facial  muscles.  These  spasms  may  be  of  varying  degrees  of  severity. 
The  eye  may  be  tightly  closed  during  the  paroxysm,  or  the  face  violently 
drawn  to  one  side.  The  attacks  are  generally  supposed  to  be  con- 
fined to  those  individuals  in  whom  there  is  a  neurotic  predisposition; 
and  Erb,  Eulenburg,  and  others  consider  tic  douloureux  to  be  a  disease  of 
central  origin,  which  seems  very  probable  for  some  reasons,  but  not  so 
much  so  when  we  take  into  account  the  fact  that  in  some  cases  the  disr.-i-i- 
may  appear  and  disappear,  there  being  occasionally  a  long  period  of  qui- 
escence, and  then  a  relapse.  Anstie  considers  that  the  spasm  is  not  di- 
rectly connected  with  the  pain,  but  is  rather  inclined  to  look  upon  it  us  a 
coincidence,  or  as  a  result  of  the  epileptic  tendency,  the  pain  and  epilepti- 
form  spasm  being  separate  expressions. 

A  very  interesting  case,  to  which  I  have  already  casually  alluded,  was 
sent  me  by  my  friend  Dr.  Sayre,  of  New  York. 

Mr.  K.  had  for  ten  or  twelve  years  suffered  from  neuralgia  of  the  fifth 
nerve  of  the  right  side.  His  habits  had  been  very  good,  and  there  was  no 
history  of  syphilis,  nor  any  evidence  that  it  had  existed.  About  ten  years 
ago,  after  exposure,  he  first  noticed  the  commencement  of  his  trouble, 
and  at  this  time  there  was  no  facial  spasm  or  very  decided  pain  ;  his 
attacks,  however,  which,  during  the  first  two  or  three  years,  occurred  at 
intervals  of  two  or  three  months,  became  much  more  frequent,  and,  within 
three  years,  have  become  almost  continuous,  so  that  there  is  rarely  an  in- 
terval of  five  or  ten  minutes  between  each  paroxysm.  Sleep  is  utterly 
impossible,  and  he  has  been  obliged  to  resort  to  an  immense  quantity  of 
stimulants  for  the  purpose  of  procuring  rest. 

He  tells  me  that  very  often  he  drinks  a  pint  of  whiskey  before  retiring. 
During  his  visit  he  had  several  attacks  of  tic,  during  which  his  face  \\;is 
drawn  up  and  agitated  by  clonic  spasm  of  the  muscles  of  the  right  side ; 
these  attacks  lasted  one  or  two  minutes,  during  which  his  face  became 
flushed,  his  eyes  injected,  and  from  the  corner  of  his  mouth  trickled  a  quan- 
tity of  saliva  ;  the  gum  was  very  tender,  and  painful  points  before  alluded 
to  were  found  to  be  very  sensitive.  Numerous  painful  points  w'ere  also 
found  upon  the  scalp  over  the  supra-orbital  notch,  and  at  different  points 
over  the  temporal  bone.  Before  I  saw  him  he  had  been  under  several 
varieties  of  treatment,  but  none  afforded  him  the  least  relief. 

CERVICO-OCCIPITAL  NEURALGIA. 

"When  the  posterior  branches  of  the  upper  cervical  nerves  are  the  seat 
of  neuralgia,  the  patient  will  complain  of  pains  beneath  the  occiput,  be- 
hind the  ear,  and  sometimes  at  the  under  part  of  the  lower  jaw.  The 
pain  at  the  base  of  the  occiput  is  most  severe;  but  when  the  neuralgia  in- 
volves the  anterior  nerve  branches,  and  pain  appears  behind  the  ear  and 
over  the  lower  part  of  the  face,  this  affection  may  be  mistaken  for  neu- 
ralgia of  the  fifth  pair.  The  pain  is  often  insupportable,  and  is  of  a  parox- 
ysmal 'character.  It  is,  on  the  other  hand,  of  a  localized  form,  and  so 
constant  in  some  cases. that  the  medical  man  may  be  led  to  suspect  inflani- 


NEURALGIA.  427 

matory  conditions  of  other  parts.  During  the  active  pain  the  patient  may 
be  unable  to  turn  his  head  or  open  his  mouth,  and  any  muscular  move- 
ment is  attended  with  distress.  The  skin  may  be  either  hypersesthetic  or 
anesthetic,  but  more  often  the  former,  and  I  have  had  patients  who  were 
unable  even  to  bear  the  pressure  of  a  collar  or  other  neck  gear.  The  skin 
feels  to  the  patient  as  if  it  were  tightly  drawn  over  the  tissues  beneath, 
and  it  sometimes  may  be  red  and  appear  swollen.  The  hyperasthesia, 
when  it  involves  the  scalp,  is  so  distressing  that  the  patient  is  unable  to 
place  his  head  upon  the  pillow,  or  wear  a  hat  unless  it  is  much  too  large 
for  him ;  and  heat  seems  to  increase  the  discomfort  to  a  marked  degree.  The 
post-cervical  muscles  may  be  the  seat  of  cramps,  during  which  the  pa- 
tient's head  is  drawn  "backwards  or  laterally  downwards.  Painful  points 
may  be  found  in  two  or  three  situations,  but  most  frequently  where  the 
great  occipital  nerve  emerges.  The  spinous  processes  of  the  upper  cer- 
vical vertebrae  are  often  the  seats  of  painful  spots,  and  it  is  not  rare  to  find 
that  distress  is  caused  by  pressure  at  different  places  over  the  occipital  bone. 

CERVICO-BRACHIAL  NEURALGIA. 

A  form  of  attack  manifesting  itself  in  severe  pains,  which  shoot  down 
the  arms,  hands,  and  back  of  the  neck.  Exquisite  cutaneous  hyperses- 
thesia  is  by  no  means  a  rare  accompaniment,  the  skin  being  so  tender  to 
pressure  that  the  slightest  touch  of  the  clothing  will  produce  intense  suf- 
fering. The  distribution  of  pain  corresponds  to  the  parts  supplied  by  the 
lower  cervical  nerves  or  regions  which  are  innervated  by  sensory  branches 
of  the  brachial  plexus. 

Erb1  has  given  a  diagram  which  demonstrates  the  districts  of  pain,  and 
their  source  of  supply,  which  may  be  made  use  of  in  tracing  the  course  of 
the  affected  nerves.  (See  page  441.) 

My  attention  has  been  directed  by  Dr.  Burral  to  a  condition  of  neu- 
ralgia which  is  often  mistaken  for  the  so-called  muscular  rheumatism,  and 
is  probably  due  to  an  involvement  of  the  circumflex  as  well  as  the  pos- 
terior thoracic.  The  pain  is  not  nearly  so  acute  as  that  of  some  of  the 
other  neuralgias  ;  for  example,  the  facial  variety.  It  is  dull  and  terebrat- 
ing,  and  resembles  the  agonizing  though  temporary  pain  which  follows  a 
blow  upon  the  popularly  called  "  funny  bone,"  or  ulnar  nerve,  in  its  ex- 
posed position  at  the  internal  condyle.  The  pain  travels  down  into  the 
hand,  and  may  be  attended  by  a  spasm  of  the  muscles.  There  are  points 
of  tenderness  which  are  extremely  numerous.  Pressure  made  over  the 
supraclavicular  space,  just  below  the  lower  angle  of  the  scapula,  at  the 
exposed  portion  of  the  ulnar  nerve  at  the  elbow,  and  at  the  points  of  emer- 
gence of  the  superficial  nerves  of  the  arm  and  forearm  as  they  pierce 
through  the  fascia,  gives  rise  to  pain.  Occasionally  there  are  tender  spots 
over  the  cervical  vertebrae.  The  skin  of  the  arm  is  often  cold,  and  areas 
of  capillary  emptiness  are  to  be  observed  either  during  an  accession  of 

1   Ziemssen's  Encyclopedia,  vol.  xi.  p.  146. 


428  DISEASES    OF    THE    PERIPHERAL    NERVES. 

pain  or  between  the  attacks.  In  rare  instances  it  is  not  unusual  for  tro- 
phic alterations  to  be  manifested.  In  a  patient  under  observation  the 
right  hand  is  reduced  in  size,  the  skin  is  dry,  puckered  and  livid  ;  tin- 
lines  of  flexure  of  the  fingers  and  hand  are  red,  and  much  deeper  than 
upon  the  other  side  of  the  body ;  and  the  nails  are  crenated  and  irregular. 
Erb  alludes  to  an  excessive  sweating  of  the  fingers.  This  form  of  neu- 
ralgia is  decidedly  inveterate,  and  when  well  established  is  attended  by 
nocturnal  exacerbations.  The  use  of  the  affected  hand  is  sure  to  aggra- 
vate or  precipitate  an  attack,  and  changes  of  temperature  act  usually  in 
the  same  manner. 

A  gentleman  sent  to  me  by  Dr.  Ives,  of  New  York,  had  suffered  in- 
tensely for  a  number  of  years,  and  his  pain  had  become  almost  constant. 
When  he  neglected  to  cover  his  arm  with  cotton  batting,  but  permitted 
his  coat  sleeve  to  come  in  contact  with  the  skin,  he  would  be  in  utter 
misery,  so  that  he  was  obliged  to  cover  it  with  some  soft  substance.  He  \\  us 
very  cautious  in  selecting  a  position  at  night,  as  the  arm,  if  unsupported, 
dragged  the  muscles  of  the  shoulder  sufficiently  to  produce  a  paroxysm. 

INTERCOSTAL   NEURALGIA,    OR   PLEDRODYXIA. 

This  is  often  mistaken  for  pleurisy.  It  is  characterized  by  a  pain  which 
encircles  the  body,  and  may  be  referred  by  the  patient  to  the  region 
bounded  by  the  crest  of  the  ilium  below,  and  the  thorax  above ;  but  it 
more  commonly  affects  the  lower  intercostal  nerves.  The  pain  is  always 
one-sided,  and  is  dull  and  continued,  but  may  sometimes  be  sharp  and 
paroxysmal,  radiating  from  the  spine  anteriorly.  The  skin  is  hypenes- 
thetic,  and  this  is  particularly  the  case  if  the  neuralgia  be  attended  by 
her|>etic  patches.  The  painful  points  are  chiefly  over  the  inter-vertebral 
foramen,  and  where  the  nerve  pierces  the  muscles  anteriorly.  The  red  us 
muscles  contain  painful  spots  at  the  points  where  the  lower  intercostal 
nerves  pierce  the  investing  sheaths.  The  patient  during  the  paroxysm 
inclines  his  body  to  the  affected  side,  as  it  were  to  relax  the  muscular 
strain ;  he  perspires  freely,  and  his  face  wears  a  scared  and  anxious  ex- 
pression, suggestive  of  great  suffering.  His  breathing  is  "catching"  and 
shallow,  and  attended  by  the  least  possible  movement  of  the  thoracic 
walls  or  diaphragm. 

SCIATICA. 

Sciatica  is  perhaps,  next  to  facial  neuralgia,  one  of  the  most  trouble- 
some and  familiar  neuralgias.  It  rarely  begins  suddenly,  but  has  a 
gradual  onset,  attended  by  a  variety  of  disagreeable  and  annoying  symp- 
toms. Cutaneous  hy persist hesia,  slight  fatigue  after  walking,  and  "sore- 
ness," a  sensation  of  dragging  or  of  heaviness  of  the  leg  and  foot,  and  a 
number  of  minor  symptoms  of  a  vague  character  precede  the  actual  pain. 
This  is  exceedingly  severe,  and  may  exist  in  a  dull  form,  and  during  its 
continuance  there  may  be  paroxysms  consisting  of  twinges  or  "  darts  " 


NEURALGIA.  429 

shooting  down  the  back  of  the  leg.  Should  the  patient,  while  sitting,  place 
his  thigh  so  that  the  nerve  shall  be  pressed  against  the  edge  of  the  chair, 
the  paroxysm  may  be  precipitated.  Anstie  has  divided  sciatica  into  three 
varieties,  one  of  which  occurs  during  comparatively  early  life,  and  is  con- 
nected with  hysteria.  It  is  dependent  generally  upon  over-fatigue,  and 
affects  anjemic  people.  It  is  the  form  which  attends  irregular  menstrua- 
tion, and  the  pain  is  quite  severe.  In  this  variety  I  have  rarely  found 
any  painful  points. 

Before  the  fourteenth  year  neuralgia  of  the  sciatic  variety  is  very  un- 
common. In  124  cases  collected  by  Valliex,  none  were  under  seventeen 
years  of  age. 

Sciatica  of  the  second  variety  is  a  disease  of  adult  life,  and  is  a  result 
either  of  exposure,  or  some  such  cause  as  continued  pressure  of  the  nerve 
through  sitting  in  an  uncomfortable  position.  It  is  not  rare  among  busi- 
ness men,  or  clerks  who  sit  upon  high  wooden  chairs  or  stools,  and  who 
generally  do  not  support  their  legs  by  placing  the  feet  upon  the  floor  or  the 
rounds  of  the  chair.  Anstie  connected  this  "  middle-aged  sciatica  "  with 
premature  decline,  and  States  that  the  patients  have  rigid  arteries,  gray 
hair,  and  the  arcus  senilis  ;  but  I  do  not  consider  that  these  indications  of 
decay  have  any  very  decided  bearing  upon  the  sciatica,  especially  in  the 
form  last  mentioned.  It  strikes  me  rather  that  the  causes  which  produce 
the  disease,  with  the  exception  of  dissipation  and  perhaps  syphilis,  gout, 
or  like  affections,  would  be  local.  Some  of  the  most  intractable  cases 
of  sciatica  I  have  ever  seen  were  persons  who  were  apparently  in  good 
general  health.  The  presence  of  "  painful  points  "  is  highly  characteristic 
of  this  form.  Foci  of  tender  nerves  may  be  found  corresponding  with 
the  emergence  of  the  sciatic  nerves  from  the  pelvis  ;  and  also  at  various 
points  corresponding  to  the  cutaneous  distribution  of  the  posterior  branches, 
as  Avell  as  just  below  the  crest  of  the  ilium.  Points  of  tenderness  may  be 
also  found  at  various  situations  in  the  course  of  the  nerve  at  the  back  of 
the  thigh ;  sometimes  in  the  popliteal  space,  or  at  the  head  of  the  fibula, 
and  in  the  depression  below  the  external  and  internal  inalleoli.  Atrophy 
of  the  muscles  of  the  thigh  is  not  a  rare  consequence  of  the  neuralgia  in 
old  cases,  and  is  sometimes  preceded  by  paresis.  Tactile  sensibility  is 
diminished,  and  areas  of  anaesthesia  or  blanching  of  the  skin  are  occa- 
sional results  of  a  continued  siege.  The  paresis  of  sciatica  is  of  gradual 
appearance,  and  the  patient  may  at  first  slightly  drag  his  leg  or  limb.  In 
some  of  the  old  cases  the  least  movement  of  the  limb  is  attended  by  pain, 
which  is  referred  by  the  patient  to  the  point  where  the  sciatic  nerve  leaves 
the  pelvis.  Such  atrophy  may  follow  inactivity. 

A  curious  feature  of  the  disease  in  some  cases  is  the  appearance  of  pain 
in  different  parts  of  the  limb.  In  the  case  of  a  Cuban  gentleman  who , 
came  to  me  for  advice,  I  found  that  there  were  two  districts  of  pain :  one 
of  which  included  the  upper  part  of  the  sciatic,  the  pain  never  passing 
below  the  middle  third  of  the  right  thigh ;  the  other  situated  at  the  outer 
side  of  the  leg  of  the  same  side. 


430  DISEASES    OF    THE    PERIPHERAL    NERVES. 

CRURAL  NEURALGIA. 

When  the  pain  is  confined  to  the  anterior  and  lateral  parts  of  the  thijrh. 
it  is  properly  included  in  the  cases  called  by  this  name,  but  the  region 
supplied  by  the  crural  and  its  branches,  viz.,  the  inner  surface  of  the  thigh 
and  its  anterior  aspect,  as  well  as  the  inner  part  of  the  leg  and  foot,  is 
more  often  the  seat  of  pain  in  the  lower  extremity  than  any  other  part, 
except  that  innervated  by  the  great  sciatic.  This  pain  is  paroxysmal, 
very  severe,  and,  like  that  of  the  cervico-brachial  variety,  most  intense  at 
night.  The  inner  part  of  the  leg  and  foot  are  most  commonly  implicated, 
and  there  is  a  subacute  variety  of  pain  which  exists  between  the  parox- 
ysms. Walking  and  muscular  movements  of  any  kind  are  painful,  ami 
the  patient  may  find  it  necessary  to  use  a  crutch,  or  else  is  obliged  to  keep 
quiet.  Foci  of  tenderness  may  be  detected  at  the  point  where  the  crural 
nerve  is  most  superficial,  in  the  groin  at  the  inner  side  of  the  knee,  at  the 
upper  and  inner  edge  of  the  patella,  and  at  various  points  on  the  inner 
side  of  the  foot  and  leg.  Muscular  atrophy,  which  is  probably  a  result  of 
insufficient  use  of  the  limb,  is  sometimes  a  feature  of  the  disease.  When 
the  pain  is  more  severe  at  the  knee-joint,  we  may  find  an  enlargement  of 
that  articulation,  and  in  some  respects  the  condition  may  resemble  arth- 
ritic inflammation  ;  but  the  cutaneous  hyperaesthesia  is  much  greater  than 
in  the  latter  affection,  while  deep  pressure  does  not  produce  the  amount 
of  pain  it  would  in  rheumatism. 

THE  VISCERAL  NEURALGIAS. 

The  visceral  neuralgias,  especially  those  found  to  be  connected  with  the 
uterus  and  its  appendages,  come  more  properly  within  the  province  of  the 
gynaecologist  than  the  neurologist ;  so  a  complete  description  would  neces- 
sitate a  consideration  of  the  various  pathological  uterine  states  which 
would  be  out  of  place  in  this  book  ;  therefore  our  description  must  be  ex- 
ceedingly brief.  The  importance  of  these  latter  forms  of  neuralgia  can- 
not be  over-estimated.  They  are  commonly  of  reflex  origin,  and  depend 
very  often  upon  some  morbid  condition  of  the  uterus  and  ovaries  them- 
selves. As  Anstie  remarks :  "  The  amount  and  force  of  the  peripheral 
influences  which  are  brought  to  bear  upon  the  central  nervous  system  by 
the  functions  of  the  uterus  and  ovaries  are  greater  than  any  that  emanate 
from  the  diseases  and  functional  disturbances  of  any  other  organ  in  the 
body."  The  menstrual  period  is  that  with  which  neuralgia  of  this  kind 
is,  in  nine-tenths  of  these  cases,  associated.  It  is  essentially  connected 
with  irritability  of  the  pelvic  organs  of  the  female,  either  when  there  is 
amenorrhcea  and  dysmenorrhoea,  or  when  the  generative  apparatus  is  over- 
excited by  immoderate  copulation  or  masturbation,  or  during  the  preg- 
nant state.  When  there  is  any  mechanical  condition  of  narrowing  or 
occlusion  of  the  cervical  canal,  prolapsus  uteri,  intra-uterine  growths, 
ulcers,  or  reflected  irritation,  neuralgia  is  not  at  all  a  rare  accompaniment. 
I  have  found  it  very  often  as  a  symptom  of  general  aniemia,  with  no  ap- 
preciable uterine  disease  whatever. 


NEURALGIA.  431 

OVARIAN  NEURALGIA. 

Ovarian  neuralgia  is  symptomatized  by  excruciating  pains  radiating 
from  these  organs.  It  is  not  necessary  that  there  should  be  derangement 
of  menstruation,  though  such  is  generally  the  case.  The  pain  may  some- 
times be  dull,  but  is  more  apt  to  be  quite  sharp.  It  is  greatly  increased 
by  standing,  or  by  fatigue  following  protracted  use  of  the  lower  extremities. 
Among  sewing-machine  operators  it  is  especially  common,  and  many  of  my 
cases  have  been  of  this  kind.  It  is  generally  connected  with  constipation 
or  a  sluggish  condition  of  the  circulation,  sometimes  leucorrhoea,  hysteria, 
and  always  with  a  great  deal  of  weariness  and  prostration.  The  suffering 
may  be  so  intense  and  protracted  as  utterly  to  wear  out  the  patient,  and  unfit 
her  for  any  labor.  It  may  be  bilateral  or  unilateral.  There  are  various 
other  forms  of  neuralgia  which  depend  upon  reflected  or  local  causes. 

URETIIRAL  NEURALGIA. 

This  is  not  infrequently  associated  with  stricture,  gonorrhoea,  or  mas- 
turbation. It  may  be  quite  obstinate  and  of  a  paroxysmal  character,  and 
is  much  worse  at  night.  I  have  found  it  very  often  where  there  has  been 
a  contracted  meatus,  in  which  case  the  pain  ran  up  the  penis.  Vesical 
neuralgia,  which  may  be  connected  with  the  presence  of  a  stone,  or  which 
occurs  as  a  result  of  long-standing  cystitis,  is  symptomatized  by  pain  at  the 
neck  of  the  bladder,  while  there  may  be  some  tenesmus. 

RENAL  NEURALGIA,  ETC. 

Renal  neuralgia  cannot  be  diagnosed  with  certainty,  and  probably  the 
pain  is  in  many  cases  due  to  the  presence  of  calculi.  Neuralgia  of  the 
testis  is  symptomatized  by  sharp  pains  of  a  temporary  character ;  and  it  is 
generally  due  to  some  distant  source  of  irritation,  such  as  the  descent  of  a 
renal  calculus,  or  the  presence  of  a  vesical  calculus.  I  have  seen  cases  which 
have  followed  excessive  venery ;  and  Anstie  reports  a  case  of  epilepsy  in 
which  this  form  of  neuralgia  was  undoubtedly  the  exciting  cause.  Self- 
abuse  produced  the  "  testicular  neuralgia,"  which  in  turn  precipitated  the 
fits.  With  the  pain  there  were  vomiting  and  great  prostration.  Ascarides 
in  the  rectum  may  give  rise  to  neuralgia  of  that  gut.  The  pain  is  nearly 
always  about  the  anus  or  just  above  the  sphincter,  and  darts  upwards. 
Cold  and  exposure  are  given  as  causes.  The  breasts  are  often  the  seat  of 
a  very  painful  neuralgia,  which  has  been  called  mastodynia.  This  is,  in 
reality,  a  form  of  intercostal  neuralgia,  in  which  case  the  anterior  and 
middle  cutaneous  branches  of  the  intercostal  of  one  or  both  sides  are 
affected.  It  appears  at  puberty,  or  may  accompany  lactation  when  the 
nipples  are  cracked.  In  both  these  classes  of  cases  there  must  be  a 
lowered  nervous  condition  ;  and,  according  to  Anstie,  masturbation  pre- 
cedes the  trouble  in  the  youthful  patient,  while  it  is  extremely  probable 
that  the  strain  upon  the  nervous  system  during  pregnancy  and  lactation 


432  DISEASES    OF    THE    PERIPHERAL    NERVES. 

is  often  much  greater  than  the  badly-nourished  patient  can  bear.  I  have 
met  with  the  affection  in  perfectly  healthy  patients,  and  am  convinced  that 
the  pain  was  purely  neuralgic,  and  not  dependent  upon  any  inflammatory 
condition  of  the  nipples.  One  of  these  patients  was  a  prostitute,  and  had 
assiduously  followed  her  trade,  meanwhile  losing  sleep,  and  drinking  to 
excess. 

Causes For  the  sake  of  conciseness,  I  may  group  the  causes  which 

are  predisposing  under  the  following  several  heads  : — 

1.  Hereditary. 

2.  General  diathetic  (anemia,  rheumatism,  alcoholism,  gout,  syph- 

ilis). 

3.  Psychical  (intellectual,  emotional). 

4.  External  (cold,  pressure). 

5.  Sexual. 

6.  Reflex. 

Hereditary  predisposition  plays  a  most  important  part  in  the  genesis  of 
neuralgia,  so  important  indeed  that  it  is  difficult  to  find  cases  of  this  dis- 
ease in  whom  there  has  not  been  some  family  history  of  previous  nervous 
trouble.  Insanity,  paralysis,  alcoholism,  or  convulsive  disorders  may  be 
traced  back ;  and  of  twenty-two  cases  collected  by  Anstie  there  were  but 
five  in  which  there  had  been  no  family  neurotic  history,  and  in  some  of 
these  phthisis  was  found.  This  disease,  according  to  Anstie  and  others, 
seems  to  play  quite  an  important  part  in  the  causation  of  neuralgia ; 
and  in  one  minutely  detailed  history  given  by  him  the  appearance  of 
tubercular  meningitis  and  other  neuro-phthisical  diseases  followed  the 
engrafting  of  the  pulmonary  trouble  upon  the  neurotic  stock.  Epilepsy 
enters  extensively  into  the  causation  of  many  forms  of  neuralgia,  especially 
epik'ptiform  tic ;  and  not  only  may  these  other  neuroses  have  appeared 
among  the  progenitors  of  the  individual,  but  they  actually  exist  with  the 
neuralgia. 

Blandford1  has  called  attention  to  a  form  of  insanity  which  coexists 
with  neuralgia,  the  pains  subsiding  during  acute  mental  disturbance,  and 
reappearing  with  its  subsidence.  Migraine  is  too  common  an  accompa- 
niment of  epilepsy  to  need  more  than  a  passing  allusion.  Chronic  alco- 
holism is  associated  with  a  variety  of  neuralgic  headaches  and  pains  in 
the  lower  extremities,  which  are  quite  intense.  Certain  general  diseases, 
which  produce  a  cachectic  condition,  quite  often  give  rise  to  the  disease, 
not  only  by  actual  mechanical  disturbance  of  the  nerve-functions  by  effu- 
sion and  periostea!  disease,  but  through  the  condition  of  mal-nutrition  and 
enfeeblement  of  the  nervous  system  which  originates  in  malaria,  gout, 
rheumatism,  and  syphilis.  The  influence  of  malaria  in  the  production 
of  neuralgia  is  markedly  seen  in  the  South  and  Southwest,  where  the 
most  violent  attacks  of  neuralgia  yield  only  to  large  doses  of  quinine  and 
arsenic.  The  neuralgia  is  generally  of  the  facial  variety,  but  it  may  take 

1  Insanity  and  its  Treatment,  p.  95. 


NEURALGIA  433 

the  sciatic  or  any  of  the  other  forms.  In  many  cases  it  is  periodic,  or 
occurs  in  connection  with  the  chill  and  other  features  of  the  malarial  at- 
tack. In  most  of  the  cases  I  have  seen,  it  followed  generally  after  a  pro- 
tracted siege  of  "fever  and  ague,"  when  there  was  extreme  debility, 
"  bone-ache,"  and  enlarged  spleen. 

Lumbo-abdominal  neuralgia  is  far  from  being  an  uncommon  malarial 
state,  and  is  sometimes  very  apt  to  be  mistaken  for  renal  colic.  Gout 
and  rheumatism  are  not  looked  upon  by  Anstie  as  diseases  which  play  a 
very  important  part  in  the  general  causation  of  neuralgia,  from  which 
opinion  I  am  inclined  to  dissent.  Putting  entirely  out  of  the  question  the 
local  inflammation  of  the  nerve-sheath,  which  is  so  often  a  cause  of  sciatica 
and  other  neuralgias,  I  am  convinced  that  there  are  forms  of  the  disease, 
aggravated  by  changes  in  temperature,  coexisting  with  painful  joints  and 
extremely  acid  urine  which  disappear  under  alkaline  treatment,  and  are 
not  clearly  examples  of  nerve-sheath  inflammation.  Gout,  inducing  very 
often  a  condition  of  general  or  cerebral  anemia,  has  been  in  my  experience 
a  very  frequent  cause  of  facial  and  other  neuralgias.  The  condition  of 
the  liver,  which  occasions  cerebral  anaemia,  melancholia,  and  over-loaded 
bowels,  may  also  induce  a  neuralgia  of  a  functional  character.  Not  only 
in  the  tertiary  form  of  syphilis,  but,  long  before  this,  neuralgia  may  often 
be  a  troublesome  symptom.  I  have  had  recently  under  my  care  an  indi- 
vidual who  had  two  years  ago  a  primary  sore,  and  has  since  had  secondary 
symptoms.  A  chancroid,  recently  contracted,  assumed  a  phagedenic 
character,  and  there  were  great  debility  and  severe  neuralgia,  which  suc- 
cumbed under  specific  treatment  and  nourishing  diet.  Profound  anae- 
mia is  very  often  found  to  be  at  the  origin  of  neuralgia  of  various  kinds. 
In  women  who  have  lost  much  blood  during  the  menstrual  flow,  or  in 
others  who  have  become  exsanguined  from  hemorrhoids,  neuralgia  is  not 
to  be  looked  upon  as  an  unusual  complication. 

The  various  constitutional  diseases  just  alluded  to  may  produce  various 
forms  of  neuralgia,  by  inflammation  of  nerve-sheaths,  with  deposit,  or,  as  in 
the  case  of  syphilis,  gummatous  growths,  or  periostitis  may  make  danger- 
ous pressure  upon  the  nerve-trunk  at  some  point  where  the  latter  is  unable 
to  withstand  it  without  injury  to  itself.  Syphilis,  in  rare  instances,  pro- 
duces irritation  in  the  nerve-trunks  themselves,  giving  rise  to  pain.  This 
irritation,  however,  much  more  frequently  produces  motor  paralysis  than 
sensory  disturbance.  Mental  overwork,  shock,  and  a  continued  abnormal 
play  of  the  emotions  are  likely  to  give  rise  to  neuralgia,  and  for  this  reason 
literary  men  and  hysterical  women  suffer  very  frequently.  The  headache 
of  the  overworked  school  child,  compelled  to  overtax  its  brain,  and  de- 
pendent upon  confinement  in  a  hot  room,  is  far  too  common.  Want  of  amuse- 
ment, deep  grief,  and  the  pursuit  of  one  narrow  line  of  thought,  are  all 
influences  which  lower  the  integrity  of  the  nervous  system,  and  give  rise 
to  this  as  well  as  other  neuroses.  Anstie's  practical  and  judicious  reasoning 
in  regard  to  false  religious  training,  and  the  dangers  it  may  bring  in  the 
way  of  forcing  the  individual  to  become  self-conscious,  should  suggest  to 
the  physician  and  parent  the  necessity  for  avoiding  everything  in  educa- 
28 


434  DISEASES    OF    THE    PERIPHERAL    NERVES. 

tion  which  promotes  brooding,  causes  the  individual  to  torture  himself 
with  doubts  and  self-accusation,  and  narrows  the  mind,  thus  depriving  tin- 
nervous  system  of  its  normal  exercise.  Constant  worry  about  business  and 
any  strain  which  demands  an  unusual  expenditure  of  brain-force  are  causes 
of  this  kind.  Exposure  to  cold  and  damp,  particularly  if  there  be  wind, 
is  a  fruitful  exciting  cause  of  neuralgia,  and  persons  who  are  exposed  to 
draughts  in  railroad  cars  and  public  buildings  very  often  owe  their  attack 
to  such  agencies.  Pressure  from  various  growths,  cystic,  cancerous,  uiul 
gummatous  deposits,  not  rarely  causes  distressing  and  intractable  neu- 
ralgias ;  but  a  syphilitic  growth  has  been  known  to  entirely  surround  a 
nerve-trunk  without  interfering  materially  with  its  functions.1  NeuronmUi 
very  frequently  give  rise  to  neuralgia.  Such  neuromata  sometimes  follow 
amputation  or  gross  nerve-wounds,  and  the  neuralgia  is  generally  relieved 
by  extirpation  of  the  nerve-tumor.  Various  local  troubles,  of  a  peripheral 
or  remote  nature,  produce  neuralgia,  and  among  these  may  be  mentioned 
carious  teeth,  ascarides,  and  renal  calculi.  When  carious  teeth  give  rise 
to  neuralgia,  it  is  always  very  obstinate,  and  the  cause  may  remain  unsus- 
pected for  a  long  time. 

Salter  has  observed  cases  of  cervico-brachial  neuralgia  from  bad  teeth  ;  the 
variety  most  frequently  met  with  however  is  facial  neuralgia.  This  cause 
is  ordinarily  supposed  to  account  very  frequently  for  the  head  neuralgias, 
and  many  sound  teeth  are  sacrificed  by  the  individual,  while  there  may  be 
neuralgia  of  the  two  lower  branches  of  the  fifth  from  other  causes.  Over- 
use of  the  eyes,  and  consequent  fatigue  of  the  muscles  of  accommodation, 
are  supposed  by  some  to  have  much  to  do  with  its  production.  Renal  or 
urethral  calculi,  gonorrhoea,  masturbation,  and  excessive  venery,  are  all 
reflex  causes  of  importance,  and  play  a  part  in  the  production  of  lumbo- 
abdominal  and  other  neuralgias.  Uterine  disease  and  overloaded  bowels, 
or  a  fibrous  tumor  in  the  rectum,  may  by  pressure  often  produce  sciatica  of 
a  very  obstinate  variety,  and  aneurism  more  rarely  makes  pressure  which 
gives  rise  to  neuralgia.  Digestive  derangement  and  prolonged  lactation 
may  be  mentioned  as  additional  conditions  which  favor  the  production 
of  neuralgia.  As  to  age  and  sex,  it  is  the  opinion  of  most  authors  that 
neuralgia  usually  originates  at  the  age  of  puberty,  but  the  disease  is  most 
common  between  the  twentieth  and  fiftieth  years.  The  following  table, 
presented  by  Erb  (Ziemssen,  vol.  xi.),  possesses  statistical  value : — 

Valleix.  Eulenburgh.      Erb.  Total. 

Period  of  life  up  to  1 0  years,  26  8 

"     10  to  20     "  22  19  14  55 

"     20  to  30     "  68  —  40  108 

"     30  to  40  "  67             33  39  139 

"     40  to  50  "  64              23  29  116 

"     50  to  60     "  47  14  14  75 

"     60  to  70     "  21  6  9  36 

"             k'     70  to  80     "  5  1  6 


296  101  146  543 


1   HuebiH-r,  Ziemssen's  Encyclopaedia,  vol.  xii. 


NEURALGIA.  435 

As  to  sex,  Valleix  collected  469  cases,  218  of  whom  were  men  ;  Eulen- 
burgh  106,  of  whom  30  were  men  ;  Anstie  100,  of  whom  33  were  men  ;  Erb 
146,  84  being  men.  Of  course  there  are  varieties  of  neuralgia  which  are 
confined  more  to  certain  ages  and  sexes.  Migraine  is  more  general  among 
women,  while  sciatica  is  probably  more  often  a  disease  of  males.  Anstie 
and  Hammond  botli  consider  facial  neuralgia  to  be  a  disease  of  adult  life. 
So  far  as  climatic  influences  are  concerned,  neuralgia  is  predisposed,  and 
very  often  markedly  affected  by  sudden  changes  in  temperature.  Dr. 
Weir  Mitchell1  has  written  a  very  valuable  paper  upon  the  subject,  which 
clearly  shows  the  very  decided  influence  of  modifications  of  temperature 
and  humidity.  His  article  is  based  upon  the  personal  notes  of  Captain 
Catlin  of  the  U.  S.  Army,  who  suffered  from  stump  neuralgia,  and  who 
intelligently  and  carefully  noted  the  influences  of  atmospheric  changes. 
Captain  Catlin's  conclusions  were  as  follows  :  "  Neuralgic  intensity  does 
not  seem  to  be  proportioned  to  the  amount  of  rain-fall.  At  the  exterior 
of  a  storm  disturbance  the  pain  is  usually  less  severe,  and,  indeed,  at 
times  I  have  been  so  far  from  the  disturbed  centre  as  to  just  percepti- 
bly feel  it.  A  storm,  reinforced  by  another  at  an  angle  of  say  90°, 
producing  greater  eccentricities  in  the  curves,  does  not  seem  to  produce 
a  corresponding  intensity  or  duration  of  the  neuralgia."  He  adds  :  "  I 
am  unable  to  state  at  what  point  within  the  disturbed  area  the  pain  would 
be  strongest.  The  abruptness  of  the  barometric  fall  does  not  seem  to  have 
much  to  do  with  the  causing  of  pain,  nor  is  the  length  of  attack  dependent 
as  it  seems  on  the  length  of  the  storm." 

Pathology. — Neuralgia  is  always  the  result  of  lowered  functional 
activity  dependent  upon  the  trophic  disturbance  of  a  sensory  nerve.  This 
is  probably  attended  by  some  change  in  the  posterior  nerve-roots,  which  is 
not  necessarily  inflammatory.  The  morbid  anatomy  of  neuralgia  has 
thrown  but  little  light  upon  the  pathology  of  the  disease,  so  our  conclu- 
sions must  be  based  upon  purely  theoretical  grounds.  Erb,  in  speaking  of 
the  nutritive  disturbances,  says  :  "  In  regard  to  the  ordinary  seat  of  this 
trophic  disturbance,  nothing  accurate  is  known  ;  but  it  is  probable  that 
the  seat  varies,  and  this  much  appears  certain,  that  for  the  most  part  a 
definite  group  of  fibres  (or  their  central  terminations)  as  they  are  combined 
to  form  a  nerve-trunk  or  branch,  is  affected.  At  what  place  in  the  length 
of  the  nerve  this  is  present  it  is  difficult  to  say,  and  perhaps  may  be  at  any 
length.  The  peripheric  fibrils  may  be  affected  at  various  points  and  vari- 
ous lengths  of  their  course,  or  the  posterior  roots  and  their  prolongation 
in  the  spinal  cord  may  be  the  seat  of  the  neuralgic  trophic  disturbance  ; 
or,  lastly,  the  central  fibrils  running  in  the  spinal  cord  or  brain  may  be 
affected  up  to  the  terminal  central  apparatus.  The  investigations  that 
have  hitherto  been  made  have  acquainted  us  with  many  important  facts, 
but  have  furnished  no  very  satisfactory  conclusion." 

The  clinical  features  of  neuralgia  enable  us  to  understand  many  of  the 
phenomena  which  ordinarily  characterize  the  disease,  and  we  are  allowed 
to  assume  that  lowered  nutrition  from  general  or  local  disease,  reflected 

1   Am.  Journ.  of  Med.  Science,  April,  1877,  p.  305. 


436  DISEASES    OF    THE    PERIPHERAL    NERVES. 

irritations,  and  mechanical  pressure  enter  into  its  production.  Instead  of 
a  normal  stimulus  being  conveyed  by  a  healthy  nerve  to  the  centre,  the 
nerve  may  be  functionally  impaired  for  conduction,  or  the  centre  so  altered 
in  its  receptive  faculty  that  the  sensation  period  is  grossly  exaggerated. 
The  receptive  faculty  of  the  peripheral  fibrils  may  be  so  exaggerated  that 
ordinary  stimuli  are  received  and  transmitted  in  a  painful  form.  Why 
the  disease  should  be  paroxysmal  we  do  not  know. 

Morbid  Anatomy. — It  is  by  no  means  a  matter  of  necessity  that  a 
nerve  which  has  been  the  seat  of  neuralgia  is  found  to  be  changed  in  struc- 
ture. Accidental  atrophy,  hyperamia,  and  indications  of  neuritis  are 
sometimes  exhibited.  Thickening  of  the  nerve  and  sheath  deposits  in  its 
neighborhood,  or  enlarged  vessels,  tumors,  aneurisms,  and  the  like,  are 
occasionally  met  with.  On  the  other  hand,  nerves  have  been  removed 
which  have  been  perfectly  healthy.  In  old  cases  of  neuralgia  the  posterior 
nerve-roots  are  nearly  always  atrophied. 

Diagnosis. — We  may  briefly  sketch  the  character  of  the  symptoms. 
The  pain  of  neuralgia  is  paroxysmal  or  dull,  with  paroxysmal  recurrences  ; 
rarely  tenderness  upon  pressure,  except  at  certain  situations.  Neuralgic 
pain  is  rarely  constant,  while  that  of  neuritis  is  quite  so.  The  pain  of 
neuralgia  follows  the  course  of  some  nerve,  is  quite  acute,  and  has  a  lanci- 
nating, terebrating,  or  shooting  character.  It  is  also  connected  with  vaso- 
motor  changes  in  the  skin.  The  existence  of  a  cause  must  be  considered, 
and  the  fact  whether  "  hereditary  predisposition"  is  present  or  not.  Facial 
neuralgia  is  very  rarely  mistaken,  and  should  not  be  when  the  fact  is  taken 
into  consideration  that  the  pain  is  generally  referred  to  one  of  the  branches 
of  the  fifth  nerve.  Pleurodynia  is  sometimes  confounded  with  pleurisy, 
but  the  absence  of  physical  signs  should  be  sufficient  to  make  the  diag- 
nosis clear.  Lumbo-abdominal  neuralgia  is  very  frequently  confused  witli 
various  painful  affections  of  the  viscera.  Among  these  may  be  mentioned 
renal  colic,  the  pain  of  nephritis,  and  intestinal  colic.  Sciatica,  from  its 
unilateral  character,  is  not  likely  to  be  mistaken  for  any  other  affection. 
The  important  indication  in  diagnosis  is  to  determine  the  variety  of  neu- 
ralgia, whether  syphilitic  or  malarial,  whether  due  to  compression  or  con- 
nected with  neuritis,  or  whether  due  to  enlargement  of  and  pressure  from 
any  of  the  abdominal  organs. 

The  following  are  to  be  remembered  and  consulted  for  guidance  in 
making  a  diagnosis — 

A.  Cause  ;  history  of  previous  attacks. 

B.  Character  of  pain  ;  paroxysmal,  inconstant. 

C.  Aggravation  by  debility  or  fatigue. 

D.  The  presence  of  "  painful  points." 

K.   Its  distribution  (following  course  of  nerves). 

F.  Karely  aggravated  by  pressure,  except  at  limited  points,  which 

correspond  to  superficial  course  of  the  nerve. 

G.  Its  general  unilateral  character. 

Prognosis — Neuralgia  of  all  kinds  is  more  curable  in  early  life  than 
in  advanced  age,  and  it  may  be  assumed  that,  when  it  has  lasted  for  many 


NEURALGIA.  437 

years,  and  is  severe  in  character,  it  will  be  most  intractable;  this  is 
especially  the  case  in  the  disorder  known  as  tic  epileptiform,  which  may 
be  said  to  be  nearly  always  incurable.  In  these  troublesome  cases  even 
removal  of  the  nerve  affords  but  temporary  relief.  When  atrophy  of  mus- 
cles has  taken  place  the  chance  of  cure  is  very  remote,  and  if  the  cause 
be  a  deep  one,  such  as  pressure  for  instance,  nothing  can  generally  be  done. 
There  is  a  bright  side  of  the  picture  however.  Functional  neuralgias,  or 
those  of  the  syphilitic  variety,  readily  succumb  to  proper  treatment;  and 
sometimes  general  nourishment  and  the  removal  of  the  exciting  cause  will 
speedily  restore  the  patient  to  his  normal  condition. 

Those  neuralgias  which  develop  later  in  life  are  attended  by  structural 
decay,  arterial  degeneration,  and  are  very  hopeless.  As  to  the  curability 
of  the  varieties  of  neuralgia,  that  of  the  fifth  nerve  is  most  persistent,  and 
intercostal  neuralgia  perhaps  least  so,  whilst  sciatica  holds  a  place  midway 
between  the  two.  As  an  example  of  a  severe  and  intractable  continued 
neuralgia,  connected  probably  with  angina  pectoris,  I  may  present  the 
case  of 

Lucy  L.  S.,  sixty-five ;  U.  S. ;  married.     Previous  History When  a 

young  child  she  fell,  striking  her  right  eye  on  a  chair-post.  For  several 
days  It  was  supposed  she  had  lost  her  sight,  but  this  was  found  not  to  be 
the  case.  After  this  she  had  pain  in  the  left  side  and  shortness  of  breath, 
whenever  she  attempted  to  run.  At  twenty-one,  she  had  an  attack  of 
cerebral  hemorrhage,  which  affected  the  right  side,  but  there  was  no 
aphasia.  This  was  accompanied  by  anaesthesia,  which  has  never  entirely 
disappeared.  About  this  time  there  were  diplopia  and  ptosis — the  latter 
symptom  being  now  present.  Supposed  pulmonary  trouble  at  twenty-four. 
Married  at  twenty-five. 

"  Before  birth  of  my  second  child,  I  was  subject  to  dizziness,  and  neu- 
ralgia of  the  fifth  nerve,  which  was  most  intense  in  the  morning. 

When  nearly  twenty-eight,  and  my  second  child  was  a  few  days  old, 
I  '  commenced  to  see  dark  spots,  sometimes  like  black  specks,  again 
like  circles  with  spotted  centres.'  When  this  child  was  three  or  four  weeks 
old,  sharp  pain  commenced  in  right  side  of  the  head.  After  sleep,  the 
pain  would  subside,  and  vision  would  improve.  At  intervals  of  from  three 
to  four  weeks,  or  when  tired,  these  blind  attacks  would  return,  accom- 
panied either  by  sharp  pain  or  dizziness  in  head.  For  the  next  eight  years 
I  was  comparatively  well,  having  occasional  '  blind  turns'  when  tired. 
At  these  times  my  forehead  would  feel  as  if  strings  were  being  pulled  in 
opposite  directions,  and  there  was  much  twitching  in  the  right  eye.  All 
these  years  there  was  some  pain  about  the  heart,  with  palpitation. 

At  forty-one  the  change  of  life  commenced,  and  I  suffered  several  years 
most  intensely. 

All  these  years  there  was  some  difficulty  around  the  heart.  Palpitation 
and  some  pain  at  intervals. 

For  the  past  three  years  pain  has  been  about  equally  divided  between 
head  and  heart ;  sometimes  commencing  in  one  and  sometimes  in  the 
other.  Some  six  months  ago  pain  seemed  to  be  settling  around  heart 
particularly.  Would  come  on  with  a  chill  and  creeping  sensation  up  the 
spine,  and  would  begin  with  a  whirling  in  left  side.  A  palpitation  of  the 
heart  would  come  on  if  excited  or  tired.  Outward  applications  and  medi- 
cine taken  seemed  to  drive  pain  across  from  left  side  to  right  shoulder. 


438  DISEASES    OF    THE    PERIPHERAL    NERVES. 

Would  go  into  right  side  of  the  head ;  follow  down  right  arm  into  hand. 
Also  into  left  arm  and  hand.  Hands  have  been  much  drawn  up,  and 
streaked  with  red.  "When  pain  was  in  face,  it  would  be  spotted  red  uiid 
white  on  right  side  only.  When  severest  in  side  and  heart,  eyes  became 
set  in  head  ;  face  livid,  and  blood  would  settle  under  nails.  After  endur- 
ing pain,  tremble  much  in  limbs." 

I  saw  the  patient  during  the  past  spring,  and  found  her  to  be  a  ratlii-r 
spare,  badly-nourished  woman,  and  she  presented  the  following  symp- 
toms : — 

Objective The  right  eye  was  examined  and  found  to  be  sightless ; 

the  retina  was  the  seat  of  an  old  neurosis,  with  atrophy  of  the  disk.  There 
was  slightly  developed  ptosis  of  this  eye,  and  some  keratitis,  corneal  opacity, 
and  ulceration,  so  that  she  was  obliged  to  wear  a  shade.  The  right  side 
of  the  face  was  slightly  anaesthetic  and  analgesic.  jEsthesiometer  contact 
and  extremes  of  temperature  were  not  readily  perceived.  The  same  was 
the  case  in  the  skin  of  the  right  arm,  forearm,  and  hand,  but  more  decidedly 
the  latter.  The  hand  presented  the  appearances  to  be  hereafter  described 
(see  article  upon  NEURITIS),  and  was  markedly  anaesthetic,  and  the  skin 
showed  evidence  of  impaired  nutrition.  The  right  lower  extremity  was  in 
a  much  better  condition.  There  was  very  slight  loss  of  motor  power  on 
the  right  side. 

Subjective She  now  has  attacks  of  severe  facial  and  cervico-brachial 

neuralgia  which  come  on  every  two  or  three  weeks,  and  lias  had  one 
within  a  day  or  two ;  there  is  still  some  tenderness  left  at  various  parts  of 
the  face  and  right  upper  extremity.  The  pain  seems  most  intense  in  the 
upper  branches  of  the  fifth,  and  has  never  affected  the  inferior  maxillary 
to  a  decided  degree.  The  arm-pain  and  head-pain  are  simultaneous  in 
their  onset,  and  are  preceded  by  the  ordinary  prodromata  of  an  attack  of 
this  kind.  They  are  always  paroxysmal,  and  seem  to  reach  a  climax  and 
then  subside.  During  the  attack  the  eye  is  seemingly  "forced  forwards." 
After  the  attack  she  is  entirely  free  from  pain.  With  the  seizure  there  is 
cardiac  trouble,  and  respiratory  trouble  which  suggests  some  impairment  of 
the  pneumogastric. 

She  never  has  convulsions  or  vomiting,  and  there  is  no  deep  localized 
pain  at  any  point  in  the  superior  aspect  of  the  cranium ;  but  all  pain  at  this 
point  is  superficial,  and  would  evidently  come  under  the  head  of  hyper- 
aesthesia. 

In  this  case  there  is  a  decided  hereditary  history  of  nervous  disease. 

Treatment. — In  nine-tenths  of  the  cases  of  neuralgia  the  manage- 
ment of  the  disease  should  be  undertaken  with  the  assumption  that  the 
pain  is  due  to  lowered  functional  activity  and  depressed  tone  ;  and  while 
local  treatment  is  not  to  be  forgotten,  it  is  absolutely  imperative  that  the 
patient  should  be  supported,  and  that  drugs  which  improve  the  nutrition 
of  the  nervous  system  should  be  selected.  It  is  well  to  minutely  inquire 
into  the  existence  of  other  disease,  and  reference  to  what  I  have  already 
said  about  etiology  will  furnish  the  reader  with  such  hints  as  may  be  neces- 
sary. Should  menstrual  irregularities,  gsistric  derangement,  or  constitu- 
tional diseases  be  found,  it  is  well,  I  may  say  absolutely  necessary,  that 
these  should  be  corrected  before  any  local  treatment  is  to  be  undertaken. 


NEURALGIA.  439 

Neuralgic  pain  is  very  variable ;  and  although,  for  my  present  purpose,  I 
shall  make  use  of  two  expressions  to  denote  its  character,  there  is  much 
that  must  necessarily  remain  unsaid  in  regard  to  its  variation  and  pecu- 
liarities. 

I  shall  describe  the  pain  of  neuralgia  as  coarse  and^/me,  two  divisions 
which,  though  somewhat  arbitrary,  are  useful  when  we  speak  of  treatment. 
Fine  neuralgic  pains  may  be  said  to  be  those  of  a  sharp  paroxysmal  cha- 
racter, leaving  behind  no  points  of  tenderness,  and  entirely  unconnected 
with  any  suspicion  of  neuritis.  Coarse  neuralgic  pains  may  be  said  to  in- 
clude the  brusque  pains,  which  bring  local  tenderness  and  soreness,  and 
are  aggravated  by  movement.  The  former  are  those  which  sometimes 
occur  during  migraine  and  functional  neuralgia  of  the  lighter  kinds;  while 
the  coarse  pains  may  be  often  the  result  of  sciatica,  in  which  the  move- 
ment of  the  limb  in  walking  or  the  pressure  of  the  chair  is  sufficient  to 
give  rise  to  them.  In  one  form  of  the  latter  our  treatment  should  be  quite 
negative,  and  of  a  character  which  necessitates  the  use  of  counter-irritants, 
such  as  blisters  and  the  actual  cautery ;  while  the  former  is  best  treated 
by  remedies  which  either  increase  the  blood-supply  of  the  nervous  centres 
and  improve  their  tone,  or  allay  reflex  irritability.  The  treatment  of 
facial  neuralgia  or  migraine  should  be  the  following  :  The  use  of  diffusible 
stimulants;  muriate  of  ammonia  (FF.  93,  94)  being,  perhaps,  one  of  the 
best.  It  should  be  given  in  large  doses  quite  frequently,  beginning  with 
from  twenty  grains  to  a  drachm,  which  should  be  repeated  every  hour 
during  the  attack.  Coffee  and  tea,  or  their  alkaloids,  are  often  serviceable ; 
or  we  may  prescribe  guarana  (F.  94),  which  is  a  very  valuable  remedy, 
in  doses  of  half  a  drachm  to  a  drachm  every  hour.  I  have  never  wit- 
nessed any  bad  results  from  the  use  of  this  drug,  even  when  quite  large 
doses  were  taken.  The  powder  is  the  best  preparation.  Tr.  belladonna 
(FF.  44,  70,  76),  given  in  small  repeated  doses,  does  much  good  if  the 
disease  be  of  a  reflex  character.  The  drugs  recommended  for  this  variety 
of  neuralgia  are  quite  as  numerous  as  most  of  them  are  useless.  The  alka- 
loids daturine  (F.  92),  and  conia  (F.  91),  have  been  used  in  obstinate  cases 
of  tic  epileptiform  with  varying  degrees  of  success,  but  great  care  should 
be  taken.  I  have  often  broken  up  an  attack  of  ordinary  facial  neuralgia 
with  a  cup  of  strong  hot  tea,  or  even  a  cup  of  hot  water  ;  and  now  have  a 
patient  who  has  been  in  the  habit  of  taking  an  emetic,  which  has  almost 
immediately  given  her  relief.  Cannabis  indica,  either  in  the  form  of  the 
extract  or  tincture,  is  of  service  when  guarana  fails.  Its  use  should  be 
continued  for  several  months.  If  the  neuralgia  be  malarial,  a  "  stiff"  dose 
(say  twenty  grains)  of  quinine  rarely  fails  .to  abate  the  paroxysm.  As 
local  applications,  various  stimulating  liniments  are  used,  the  best  I 
know  being  the  compound  soap-liniment;  or  a  mixture  of  chloroform, 
tr.  aconite  and  camphor  (F.  63),  an  ointment  of  veratria  (F.  65),  or  of 
chloral  and  camphor  (F.  67),  sometimes  afford  relief,  and  I  have  wit- 
nessed the  good  effects  of  a  tincture  made  of  the  berries  of  the  belladonna 
(F.  95).  The  blister  or  actual  cautery  may  be  brought  into  requisition  if 


440  DISEASES    OF    THE    PERIPHERAL    NERVES. 

Fig.  49. 


Cam.  7Hn'ftli.t_  _ 


Dot])  Peroneal. 


NEURALGIA.  441 

SUPERFICIAL  POINTS  AND  CUTANEOUS  AREAS  OP  NERVE  DISTRIBUTION.— 1,  2,  3,  4.  Points  for 
galvanization  of  fifth  nerve.  5.  Brachial  plexus.  6.  Musculo-cutaneous.  7.  Median.  8,  9. 
Ulnar.  11,  12.  Crural.  13.  Peroneal.  14.  Tibial.  15.  Occipital.  16.  Radial.  17,  18.  Sciatic. ' 
19.  Popliteal.  20.  Peroneal.  ac.  Acromial.  Cir.  Circumflex.  Int.  h.  Internal  humeral  Ext.e. 
External  cutaneous.  Int.  c.  Internal  cutaneous,  c.  p.  Cutaneous  palmaris.  p.  u.  Palmaris 
ulnaris.  m.  Median.  Had.  Radial.  u.  Ulnar.  Mus.  Sp.  Musculo-spiral.  Ilin-Hy.  Ilio- 
hypogastric.  /.  /.  Ilio-inguinal.  Lat.  Cut.  Lateral  cutaneous.  E  S.  External  spermatic. 
Lum.  I.  Lumbo-inguinal.  Poa.  C.  Posterior  cutaneous,  ob.  Obturator,  ctnm.  p.  Communicating 
peroneal.  In.  sa.  Internal  saphena.  Sup.  p.  Superficial  peroneal.  cpm.  Posterior  median 
cutaneous.  Cpp.  Cutaneous  plantaris  proprius.  Pll.  Plantaris  lateralis. 

painful  points  are  found,  and  I  have  been  in  the  habit  of  using  the  ether 
spray  just  in  front  of  the  ear  in  migraine.  In  tic  douloureux  I  am  convinced 
that  there  is  no  better  remedy  than  gelseminum  given  in  large  doses,  begin- 
ning with  n^viij  to  n^xv  of  the  tincture  or  fl.  extract  (F.  50).  My  friends 
Drs.  Kinnicutt  and  Clymer  have  both  mentioned  to  me  the  details  of  cases 
where  by  accident  the  patient  had  taken  toxic  doses  of  this  drug.  In  one 
of  these  the  disease  entirely  disappeared  after  the  alarming  effects  of  the 
remedy  had  passed  away.  Croton-chloral  (F.  47),  which  has  lately  been 
recommended  for  facial  neuralgia,  I  am  convinced  has  been  overpraised ; 
I  have  given  it  a  fair  trial,  and  have  rarely  found  it  of  any  use.  If  it  is 
employed  twice  a  day  in  twenty-grain  doses,  it  will  do  more  good  than 
in  the  small  repeated  doses.  The  removal  of  carious  teeth  is  often 
followed  by  speedy  disappearance  of  the  disease.  Should  the  face  become 
tender,  as  it  not  uncommonly  does,  the  patient  should  be  directed  to  keep 
it  carefully  protected  by  cotton-batting ;  and  if  painful  points  remain 
in  the  roof  of  the  mouth  or  gums,  they  may  be  lightly  touched  with  the 
hot  glass  rod  or  iron.  The  treatment  of  cervico-brachial,  cervico-occipital, 
and  other  neuralgias  of  the  trunk  may  be  managed  after  very  much  the 
same  plan.  In  each  particular  case  of  course  the  treatment  varies.  If 
there  be  a  diathetic  condition,  such  as  syphilis,  mercurial  inunctions, 
baths,  and  specific  treatment  (FF.  17, 18, 19,20,  45)  are  to  be  made  use  of 
in  conjunction  with  local  applications.  The  advantage  of  large  doses  of 
quinine  in  cachectic  headaches,  as  well  as  in  intercostal  or  lumbo-abdo- 
minal  neuralgia,  especially  if  there  be  an  herpetic  eruption,  I  have  men- 
tioned. In  these  forms,  as  well  as  in  ovarian  neuralgia,  the  use  of  local 
cold,  such  as  may  be  obtained  by  ice-bags,  or  the  application  of  blisters, 
is  very  efficacious.  The  actual  cautery,  employed  to  make  sweeping 
strokes  along  the  course  of  the  nerve,  or  down  the  back  on  either  side  of 
the  spinous  processes,  and  in  paths  which  run  at  right  angles  to  the  lon- 
gitudinal "  stripes,"  may  be  brought  into  requisition,  and  applied  twice  or 
thrice  weekly.  Sciatica  sometimes  demands  most  obstinate  treatment. 
The  actual  cautery,  and  even  nerve-stretching,  may  be  necessary  ;  but  in 
the  majority  of  cases  galvanization  of  the  nerve  does  great  good,  and 
should  be  faithfully  tried  before  anything  else  is  done. 

Electricity  affords  very  decided  relief  in  this  disease ;  and  galvanism, 
when  judiciously  employed,  rarely  fails  to  modify,  if  not  cure  neuralgia. 
In  facial  neuralgia  it  should  be  applied  to  the  nerve  by  small  sponge-covered 
electrodes,  one  pole  being  placed  just  behind  the  condyle  of  the  jaw,  and 
the  other  held  for  a  few  minutes  over  the  supra-orbital  and  infra-orbital 


442  DISEASES   OF    THE    PERIPHERAL    NERVES. 

foramina,  or  over  the  symphysis  of  the  lower  jaw.  The  current  should  be 
the  direct  (from  positive  to  negative,  the  negative  pole  being  peripheral). 
The  admirable  plates  of  Beard  and  Rockwell,  and  the  suggestions  of 
Ziemssen,  will  enable  the  reader  to  comprehend  the  situation  of  the  points 
corresponding  to  the  superficial  course  of  the  various  nerve-trunks,  so  that 
they  shall  be  brought  most  readily  under  the  influence  of  the  current. 
Faradism  of  the  intercostal  nerves,  and  of  regions  of  distribution  of 
terminal  filaments  of  other  nerves  in  various  neuralgias,  is  of  great  service, 
and  rarely  fails  to  afford  relief  in  sciatica.  I  have  seen  pleurodynia  dis- 
appear in  ten  minutes  after  the  use  of  the  faradic  current.  The  following 
case  shows  the  value  of  electrical  treatment. 

Mr.  S.  After  constant  exposure  during  the  war,  the  patient  con- 
tracted a  low  typhoid  fever,  which  left  him  weak  and  emaciated  for  a 
long  time.  Since  18G8  he  has  had  twinges  of  pain  down  the  back  part  of 
the  leg,  which  have  left  him  in  a  perpetual  state  of  misery,  with  only  oc- 
casional intervals  of  several  months  when  he  is  absolutely  free  from  pain. 
In  winter  his  trouble  is  worse,  and  any  exposure  will  immediately  pro- 
duce a  severe  attack  of  neuralgic  pain.  Any  indiscretion  in  his  diet  will 
also  be  followed  by  the  sciatica.  He  had  gone  through  the  usual  siege  of 
medication,  including  morphine,  hypodermics,  and  stimulating  lotions. 
He  came  to  me  in  July,  1871,  when  I  made  applications  of  galvanism  to 
the  nerve  by  the  conical  sponge-electrode,  the  sponge  being  held  firmly 
over  the  obturator  foramen.  At  the  first  visit  his  pain  was  excessive,  but 
after  fifteen  minutes'  application  he  left,  feeling  a  sense  of  relief  which  he 
had  not  known  for  months.  Two  months  and  a  half  of  this  treatment 
were  sufficient  to  dispel  the  pain,  which  did  not  recur.  Four  months 
afterwards,  he  made  a  visit,  when  he  stated  that  he  had  not  had  any  re- 
turn. 

In  the  treatment  of  neuralgic  attacks  the  hypodermic  syringe  has 
played  a  very  important  part.  J  have  no  doubt  that  it  has  been  abused, 
and  I  have  become  painfully  aware  that  individuals  have  thus  acquired 
the  habit  of  opium  and  morphine  self-administration.  For  the  radical  cure 
of  certain  varieties  of  neuralgia,  the  hypodermic  syringe  has  no  equal. 
My  friend,  Dr.  T.  M.  B.  Cross,  was  the  first,  I  believe,  to  use  deep  in- 
jections of  morphine  in  sciatica.  He  has  recommended  that  the  point  of 
the  syringe  needle  be  carried  down  to  the  sheath  of  the  nerve,  and  the 
contents  of  the  barrel  gradually  expelled.  Strange  to  say,  very  few  acci- 
dents have  followed  its  use,  although  the  wounding  of  an  artery  is  not  an 
impossibility.  Chloroform  has  been  used  hypodermically  by  Bartholow,1 
and  with  great  success,  and  though  I  have  produced  abscesses  in  this  way, 
I  am  inclined  now  to  acknowledge  its  value  as  a  therapeutic  measure. 
Morphine  and  atropine  (F.  a9),  dat urine  (F.  92),  ergotine  (F.  60),  and 
other  alkaloids  are  constantly  used,  and  sometimes  afford  relief,  which  is 
generally  temporary,  but  occasionally  permanent.  The  general  treatment 
is,  however,  all  important,  and  iron,  strychnine,  arsenic,  cod-liver  oil, 
and  phosphorus  (FF.  24,  25,  26,  8,  9,  10,  32)  rank  high  as  valuable 

1  Mat.  Medica  and  Therapeutics,  p.  321,  et  seq. 


NEURALGIA.  443 

remedies.  I  have  spoken  of  quinine.  I  may  add  that  when  given  con- 
tinuously, either  in  combination  or  alone,  it  cannot  fail  to  do  good.  Phos- 
phorus always  does  good,  except  in  forms  of  neuralgia  which  are  not 
directly  dependent  upon  depraved  nutrition,  and  are  due  to  cold  or  at- 
tended by  inflammatory  conditions.  Thompson's  solution  (F.  25)  is  the 
best  preparation.  Salt  air,  with  alternations  of  mountain  air,  nourishing 
diet,  which  should  include  a  large  proportion  of  non-nitrogenous  food, 
attention  to  the  daily  habits,  the  removal  of  fecal  accumulations,  and  the 
re-establishment  of  menstrual  regularity  are  of  the  greatest  importance, 
and  should  be  accomplished  if  possible. 


444  DISEASES    OF    THE    PERIPHERAL    NERVES. 


CHAPTER  XVI. 

DISEASES  OF  THE  PERIPHERAL  NERVES  (CONTINUED). 
NEURITIS. 

Symptoms — Inflammation  of  a  nerve  is  expressed  chiefly  by  sore- 
ness and  tenderness,  and  not  by  the  darting  or  paroxysmal  pain  which 
constitutes  neuralgia.  When  confined  to  the  nerve-trunk  various  depraved 
conditions  of  sensibility,  motility,  and  trophism  may  follow,  which  are 
expressed  by  cutaneous  and  muscular  changes ;  and  the  course  of  the  nerve 
can  usually  be  marked  with  great  exactness,  for  pressure  produces  great 
pain.  The  skin  may  be  red  or  the  seat  of  bullous  or  pemphigous  erup- 
tions. Of  course  very  much  depends  upon  the  character  and  importance  of 
the  nerve  affected.  Some  of  the  nerves  of  sensibility,  such  as  the  fifth,  when 
subject  to  neuritis,  are  followed  by  symptoms  different  from  those  which 
occur  when  the  seventh  or  one  of  the  mixed  nerves  is  affected.  Peripheral 
inflammation  of  the  external  portion  of  the  seventh  is  often  the  cause  of 
facial  paralysis,  and  neuritis  of  the  fifth  may  occasion  disorders  of  sensi- 
bility as  well  as  ulceration  of  the  cornea  and  other  trophic  phenomciiii. 
"With  neuritis  there  is  not  infrequently  loss  of  tactile  sensibility  and 
sense  of  appreciation  of  temperature,  though  in  the  beginning  the  skin  is 
hypenesthetic,  and  the  pain  is  aggravated  by  contact  with  cold  or  hot  sub- 
stances. Erb  speaks  of  acute  and  chronic  neuritis,  the  former  depending 
upon  traumatism,  sloughing,  or  cancer,  and  beginning  with  a  chill,  fol- 
lowed by  fever,  headache,  and  sleeplessness.  The  pain  commences  in  the 
affected  member,  and  extends,  until  finally  chronic  neuritis  is  progressive, 
the  inflammation  spreading,  and  involving  new  nerves.  This  extension 
may  be  recognized  by  the  fresh  appearance  of  pain  in  new  localities ;  by 
painful  points  (Valleix's)  at  new  regions,  by  difference  in  the  form  of  pain, 
and  by  variations  attending  pressure  ;  the  whole  limb  is  affected.  This 
author,  as  well  as  Mitchell,  considers  that  it  is  most  intense  at  night,  and 
that  it  is  augmented  by  movement.  Mitchell  has  observed  intense  hys- 
terical excitement,  and  even  delirium.  A  red  line  usually  marks  the 
course  of  the  affected  nerve,  and  there  may  be  patches  of  herpes  or  pem- 
phigus, or  the  skin  may  be  cedematous.  In  one  case,  observed  at  the  Epi- 
leptic Hospital,  the  patient,  a  negress,  presented  symptoms  of  neuritis  of 
the  anterior  tibial  nerve,  and  the  skin  of  the  fore  part  of  the  right  leg  was 
tense,  shiny,  and  exquisitely  sensitive.  A  marked  rigor  ushered  in  its 
development,  and  there  were  subsequently  nausea  and  vomiting.  Her 
pulse  was  feeble  and  rapid,  and  she  could  not  sleep,  and  entirely  lost  her 
appetite.  There  was  no  inflammation  whatever  of  the  skin  or  muscular 
tissue,  and  the  acute  pain  subsided  in  a  few  weeks,  but  there  remained  a 


NEURITIS.  445 

condition  of  great  tenderness.  Hot  and  cold  applications  increased  the 
pain. 

Paralysis  may  follow,  and  is  by  no  means  uncommon.  The  patient 
generally  recovers  in  a  month  or  so,  and  sometimes  in  a  shorter  time,  but 
the  neural  condition  never  entirely  disappears.  In  the  chronic  form  the 
onset  may  be  gradual  or  spontaneous,  or  follow  an  acute  attack.  I  have 
sufficiently  sketched  the  symptoms,  and  will  only  add  that  muscular  cramps, 
tremor,  or  permanent  contractures  sometimes  form  very  distressing  sequelae, 
and  with  these  there  is  paralysis.  Anaesthesia  or  hypersesthesia  is  con- 
nected with  neuritis,  the  former  being  of  late  appearance.  Erb  calls 
attention  to  the  comparative  immunity  of  the  motor  nerves,  as  paralysis 
does  not  follow  until  after  a  long  train  of  sensory  disturbances,  but  reflex 
disturbances  are  not  uncommon.  These  may  consist  in  remote  nerve  pain, 
cramps  of  distal  muscles,  or  hysterical  attacks.  The  electric  excitability 
in  the  early  stages  is  exaggerated  later,  or  it  is  lost,  and  if  there  be  para- 
lysis there  is  very  marked  muscular  atrophy  as  a  consequence,  and  electric 
contractility  disappears  altogether.  By  far  the  most  interesting  changes 
are  those  of  a  trophic  character.  Weir  Mitchell  has  presented  the  most 
complete  description  of  these  structural  alterations.  The  finger-nails  lose 
their  normal  character,  and  become  horny  and  curved,  and  the  skin 
becomes  rough  and  is  sometimes  exfoliated. 

As  additional  evidences  of  this  defective  nutrition,  "  hang  nails,"  crack- 
ing of  the  skin  and  other  slight  changes  from  its  healthy  condition  are 
striking  indications.  The  illustration  (Fig.  50)  which  I  produce  is  from 

Fijr.  50. 


Trophic  Change  of  the  S'.du. 


the  photograph  of  a  patient  whose  hand  had  been  anesthetic  for  some 
years.  The  skin  is  hard,  the  palmar  furrows  are  sharp  and  exaggerated, 
imd  the  bases  are  red  or  purple,  somewhat  resembling  the  same  api  c-ur- 


446  DISEASES   OF    THE    PERIPHERAL    NERVES. 

ance  in  the  cutaneous  flexure  of  the  knee,  elbow,  or  other  articulating 
parts  in  certain  forms  of  chronic  eczema. 

Causes. The  acute  variety  is  dependent  upon  injuries  of  various 

kinds.  I  have  seen  one  case  which  followed  a  carbuncle  situated  upon  the 
inner  surface  of  the  forearm,  and  Mitchell  reports  several  cases  following 
gunshot  wounds.  Flying  splinters,  fractures,  and  blows  are  various  trau- 
matic causes,  while  the  extension  of  cancerous  disease  or  sloughing  may 
produce  a  neuritis.  Cold,  rheumatism,  and  syphilis  enter  into  the  etiology 
of  the  affection,  and  Mitchell  has  produced  a  neuritis  by  the  local  applica- 
tion of  ice.  In  one  case  of  facial  spasm,  for  which  I  used  the  ether  spray, 
I  was  disagreeably  surprised  to  find  a  remaining  neuritis  of  the  portio 
dura,  which  lasted  for  some  time. 

Beau  has  directed  attention  to  forms  of  neuritis  of  the  intercostal  nerves 
which  undoubtedly  arose  from  pleurisy  and  pleuro-pneumonia.  Typhoid 
fever,  diphtheria,  and  other  diseases  of  a  febrile  nature  are  not  infre- 
quently attended  by  neuritis,  and  in  one  case  of  typhus,  reported  by  Bern- 
hardt,  a  neuritis  involved  the  musculo-spinal  nerve. 

Morbid  Anatomy  and  Pathology — Inflammation  of  a  nerve- 
trunk  produces  very  decided  changes  in  its  appearance.  It  becomes 
swollen,  is  of  a  pinkish  hue,  and  there  is  often  an  exudation  which  is  found 
between  the  fasiculi ;  this  may  be  also  of  a  reddish  color.  The  micro- 
scopical appearance  of  the  nerve  is  still  more  characteristic.  The  nerve- 
fibres  undergo  marked  changes  ;  the  axis,  cylinder,  and  the  medullary  con- 
tents are  disintegrated  ;  the  neurilemma  may  be  distended  by  serous  exu- 
dation, and  the  bloodvessels  are  enlarged  and  in  places  ruptured,  so  that 
blood-elements  may  be  found  scattered  in  different  regions.  In  later  stair"-" 
there  may  be  atrophy  or  fatty  degeneration.  In  chronic  neuritis  these 
appearances  of  advanced  degenerative  changes  are  found  to  consist  in 
proliferation  of  connective  tissues,  and  this  takes  place  as  an  interstitial 
formation.  Degeneration  of  the  minute  nerve-elements,  deposition  of  oil- 
globules,  and  sclerosed  patches  are  found  in  old  cases. 

If  the  inflammatory  action  be  very  severe,  the  nerve  will  be  found  to  be 
completely  destroyed  by  sloughing.  The  nerve  may  be  found  the  seat  of 
enlargements,  which  are  to  be  seen  at  different  localities  in  its  course, 
and  at  each  of  these  ]K>ints  there  may  be  a  different  kind  of  change.  In- 
flammation of  a  nerve-trunk,  as  I  have  said,  is  first  attended  by  sensory 
changes,  which  may  be  local,  or  in  other  parts ;  as  the  result  of  reflected 
irritability ;  afterwards  trophic  changes  may  result  either  from  the  pro- 
duction of  some  pressure  upon  other  parts,  or  through  loss  of  function  of 
the  nerve  itself. 

Diagnosis — The  limitation  of  the  pain,  its  aggravation  by  pressure, 
its  constancy,  and  its  character,  enable  us  to  generally  distinguish  it  from 
neuralgia.  In  chronic  neuritis  it  is  not  so  easy  to  make  such  a  diagnosis. 
The  painful  |K>ints  found  in  neuralgia  may  be  mistaken  for  the  sensitive 
8[>ots  in  neuritis.  I  have  seen  very  few  ca*es  in  which  the  pain  of  neuritis 
was  not  constant,  and  this  is  not  the  case  in  neuralgia,  which  is  essentially 
a  paroxysmal  disease.  Painful  swelling  of  the  nerve  and  paralysis  of  mus- 


NEURITIS.  447 

c\e$  supplied  are  also  evidences  of  neuritis,  which  will  aid  us  in  discover- 
ing the  nature  of  the  affection. 

Muscular  rheumatism  has  been  spoken  of  by  Erb  as  a  condition  with 
which  the  disease  under  consideration  may  be  confounded.  I  consider 
such  a  distinction  to  be  a  refinement  of  diagnosis  which  cannot  be  made. 
"  Muscular  rheumatism"  is,  after  all.  a  low  grade  of  diffused  neuritis, 
and  the  most  we  can  do  is  to  discover  the  cause  of  such  pain. 

Erysipelas,  thrombosis,  and  embolism  are  distinguished  by  the  evidences 
of  subcutaneous  swelling,  oedema,  etc.,  and  by  their  somewhat  diffuse 
character. 

The  presence  of  a  traumatism  should  be  taken  into  account,  and  its  nature 
investigated. 

Prognosis — Structural  alteration  of  a  nerve  must  follow  an  inflam- 
mation such  as  has  been  described,  and  unless  the  symptoms  have  been 
very  slight  there  is  a  tendency  to  continuance,  so  that  an  attack  of  acute 
neuritis  assumes  a  chronic  character.  If  the  inflammation  has  advanced 
centrally,  so  that  a  new  plexus  is  involved,  the  prognosis  is  very  bad. 
Treatment  has  much  to  do  in  some  cases  with -prognosis. 

Treatment. — To  Mitchell  we  are  indebted  for  excellent  directions 
for  the  management  of  neuritis.  He  tried  elevations  of  the  leg  or  arm, 
while  bladders  of  ice  were  applied  to  every  part  of  the  limb,  and  ^  gr. 
hypodermic  doses  of  atropia,  with  ^  gr.  doses  of  sulph.  of  morphia,  were 
injected  every  four  hours,  or  oftener.  He  has  used  leeches,  so  that  con- 
siderable local  abstraction  of  blood  should  take  place.  Perfect  quiet  is 
highly  important,  and  he  recommends  splints  for  the  purpose.  I  have 
used  the  plaster  bandage  in  a  way  to  leave  the  course  of  the  painful  nerve 
exposed.  The  actual  cautery  is  invaluable,  especially  when  the  disease  is 
chronic,  and  it  should  be  freely  applied  along  the  painful  tract.  Faradi- 
zation does  good,  but  I  have  no  faith  in  the  galvanic  current,  which  only 
increases  the  pain.  Hypodermics,  either  of  morphia,  atropia,  or  ergotine 
(FF.  59,  60,  61),  in  the  neighborhood  of  the  painful  point,  may  be  continued 
for  some  time,  with  the  effect  of  diminishing  the  pain  and  the  violence  of 
the  inflammation.  Large  doses  of  iodide  of  potassium  are  of  especial 
service ;  and  I  have  lately  recommended  inunctions  of  mercurial  ointment 
with  excellent  results.  This  latter  treatment  is  that  which  we  are  to 
employ  when  syphilis  is  suspected  ;  and  the  good  effects  are  sometimes  seen 
in  a  few  days.  As  a  dernier  ressort  nerve-section  may  be  resorted  to ;  but 
if  the  neuritis  has  involved  a  nerve-plexus  it  does  no  good.  It  is  only 
when  a  peripheral  nerve  is  affected  that  it  removes  the  disease. 

In  nerve-stretching — a  new  and  extremely  valuable  surgical  procedure 
— we  possess  a  means  which,  though  not  extensively  tested  as  yet, 
promises  to  be  of  great  service.  The  nerve  is  exposed,  and  forcibly  pulled, 
so  that  the  limb  shall  be  raised.  In  one  instance  the  portion  of  the  lower 
extremity,  including  the  leg  and  foot,  was  drawn  up  by  the  sciatic,  which 
had  been  bared  in  its  course  down  the  thigh. 


448  DISEASES   OF    THE    PERIPHERAL    NERVES. 

ANESTHESIA. 

Symptoms An  impairment  or  loss  of  cutaneous  or  muscular  sensi- 
bility, either  localized  or  extensive,  may  be  the  result  of  central  disease,  or 
it  may  be  of  a  strictly  peripheral  nature.  It  is  of  the  latter  that  I  now 
propose  to  speak. 

The  anaesthesia  may  imply  loss  of  the  sense  of  appreciation  of  extremes 
of  temperature,  contact,  or  painful  impressions. 

In  the  optic  nerve,  amaurosis  is  a  result,  and  with  this  there  is  commonly 
anaesthesia  of  the  ciliary  nerve,  so  that  the  influence  of  light  possesses  no 
irritant  effect.  Deafness  follows  auditory  anaesthesia,  and  loss  of  taste 
anaesthesia  of  the  lingual  nerve. 

Anaesthesia  and  analgesia  may  exist  alone  or  in  complication,  and  we  are 
constantly  reminded  of  this  state  in  cases  where  operations  are  performed 
on  insensible  parts,  the  individual  only  feeling  the  power  of  traction  or  the 
contact  of  the  surgical  instrument.  This  is  often  observed  in  some  of  the 
uterine  operations ;  and  Dicff'enbacli1  alludes  to  the  anaesthetic  condition 
produced  by  some  of  the  agents  employed,  which  only  blunt  sensibility, 
while  the  sense  of  contact  still  is  preserved.  I  have  myself  witnessed  this 
phenomenon  in  patients  in  whom  local  anaesthesia  had  been  used. 

In  cutaneous  anaesthesia  a  warm  or  cold  body  is  not  appreciated  as 
such,  but  the  individual  can  sometimes  tell  its  shape,  or  feel  the  pressure 
made.  A  lump  of  ice  is  said  to  be  irregular.  The  button  of  the  heated 
cautery  iron,  if  pressed  against  the  skin,  produces  no  discomfort,  but  only 
a  sense  of  weight.  This  loss  of  tactile  sensibility  is  generally  abolished, 
however,  or  greatly  diminished.  The  patient  will  either  not  feel  the 
points  of  the  a'sthesiometer  at  all,  or,  if  he  does,  will  be  unable  to  tell  how 
widely  they  are  separated. 

The  local  temperature  and  vascular  supply  are  altered  in  many  cases,  so 
that  the  warmth  of  the  spot  which  lias  become  anaesthetic  is  a  degree  or 
two  below  that  of  the  sound  parts  adjacent.  The  vascular  alterations  are 
attended  by  bloodlessness  and  whiteness  of  the  affected  region.  This 
diminished  blood-supply  of  course  invites  pathological  alterations  of  nutri- 
tion, for,  when  subjected  to  influences  of  temperature  or  injury  which  other 
normal  districts  would  bear  without  damage,  the  anaesthetic  skin  becomes 
rapidly  altered  as  far  as  its  integrity  is  concerned.  Romberg2  alludes  to 
the  occurrence  of  blisters  and  ulcerations  which  were  readily  caused  during 
cold  weather;  and  I  have  repeatedly  seen  the  effects  of  injurious  pressure, 
of  surgical  operations,  and  of  the  application  of  irritants.  In  one  patient 
brought  to  me  I  was  surprised  to  find  an  extensive  ulceration  of  the  skin 
of  the  forearm,  which  had  resulted  from  the  use  of  a  stimulating  liniment 
which  the  patient  had  used  with  the  idea  of  improving  an  anaesthetic  state 
dependent  upon  rheumatism. 


1  Du  JEtht'rgegen  den  Schmcrz,  1847,  p.  61. 

2  Manual  of  the  Nervous  Diseases  of  Man,  p.  202. 


ANAESTHESIA.  449 

Anesthesia  of  the  Fifth  Pair — This  form  of  anaesthesia  is  commonly 
of  peripheral  origin,  and  of  thirty -five  cases  collected  by  Ortel-Ebrard1  it 
resulted  but  nine  times  from  intracranial  tumors.  It  is  of  spontaneous 
origin  usually ;  and  the  upper  branch  is  most  profoundly  affected,  so  that 
the  loss  of  sensibility  is  limited  to  the  brow  and  region  about  the  eye,  by 
anaesthesia  of  the  cornea,  and  consequent  nutritive  changes  in  that  part  of 
the  optical  apparatus.  A  case  of  this  kind  was  reported  by  Dr.  H.  D. 
Noyes,2  of  New  York,  in  which  there  was  very  decided  sloughing  of  the 
cornea.  The  phenomena  following  anaesthesia  of  this  nerve  may  be  thus 
tabulated : — 

(  Anaesthesia  of  upper  eyelid 

Involvement  of  ophthalmic  branch.  and  forehead.     Irritating 

(      substances  are  not  felt. 
f  Anaesthesia  of  middle   por- 

Involvement  of  superior  maxillary  branch.  J      tion  of  face.    Insensibility 

(     of  gums  of  upper  jaw. 
Anaesthesia  of  skin  of  lower 
portion  of  face  ;  increased 
Involvement  of  inferior  maxillary  branch.   1      flow  of  saliva  ;  mastication 

difficult ;    gums    of  lower 
I     jaw  insensible. 

The  patient  sometimes  finds  that  the  edge  of  the  tumbler  or  vessel  from 
which  he  drinks  occasionally  feels  as  if  it  were  broken.  Several  of  these 
cases  are  reported  by  Bell.3  In  one  of  my  cases  the  patient  could  not 
spit  in  a  straight  line,  while  the  secretion  of  saliva  was  quite  abundant. 
This  same  patient  complained  that  his  gums  were  insensitive.  These 
peculiar  buccal  and  labial  symptoms  are  generally  early  and  prominent 
expressions.  Sense  of  smell  and  sensibility  of  the  nostrils  and  tongue  are 
lost  when  other  branches  are  affected. 

When  the  radial  nerve  is  the  seat  of  the  peripheral  trouble,  it  will  be 
found  that  the  back  of  the  hand  retains  its  sensibility.  The  lower  ex- 
tremities may  be  affected  when  the  condition  is  the  result  of  pressure 
made  upon  the  sciatic,  and  in  the  case  of  several  skin-diseases  the  loss  of 
sensibility  may  be  general.  Leprosy,  syphilitic  alopecia,  and  other  skin- 
diseases  may  all  be  attended  by  loss  of  cutaneous  sensation,  which  is  the 
i-esult  of  local  dermal  alteration  of  function.  Bulkley4  has  very  ably 
considered  this  subject. 

Causes. — Cutaneous  anaesthesia  may  be  due  to  pressure  made  upon 
a  nerve-trunk  in  its  course,  or  to  the  compression  of  peripheral  areas  of 
greater  or  less  extent,  or  to  local  impairment  of  function  by  exposure  to 


1  Paralysie  du  Trijemineau,  Thfese  Paris,  1867. 

2  N.  Y.  Medical  Journal,  1871. 

3  The  Nervous  System,  etc.,  3d  ed.,  p.  338,  et  seq. 

»  The  Relations  of  the  Nervous  System  to  Diseases  of  the  Skin.     Archiv.  of 
Elect,  and  Neurology,  1874-5. 
29 


450  DISEASES    OF    THE    PERIPHERAL    NERVES. 

cold,  to  certain  chemicals,  or  to  like  agents  ;  while  general  diseases,  such 
as  syphilis  or  rheumatism,  by  local  disease  and  infiltration,  greatly  alter 
the  function  of  cutaneous  nerve-filaments.  Intense  cold,  liniments  which 
contain  aconite,  or  long  immersion  of  the  hands  in  fluid  of  any  kind,  will 
result  in  a  loss  of  sensibility.  One  of  my  patients  was  a  dyer,  whose  hands 
were  kept  in  warm  dye-liquids  for  many  hours ;  and  some  of  the  French 
writers  give  examples  of  the  disease  among  washerwomen.  Alkaline 
fluids  are  more  favorable  to  its  production  than  any  others.  Tight  splints, 
blows,  diphtheria  and  other  acute  maladies,  hysteria,  and  several  other 
conditions  play  a  part  in  its  etiology. 

Diagnosis — Peripheral  anaesthesia  must  be  diagnosed  from  the  cen- 
tral condition,  and  it  is  necessary  that  we  should  bear  in  mind  not  only 
the  anatomical  arrangement  of  the  nervous  supply,  but  the  coexistence  or 
absence  of  symptoms  of  central  disturbance.  Among  the  latter  are  loss 
of  power,  which  usually  accompanies  the  anaesthesia,  or  one  or  more  of  the 
many  symptoms  previously  alluded  to. 

Trigeminal  anaesthesia  is,  perhaps,  more  difficult  to  trace  out  than  that 
of  other  nerves.  Romberg1  thus  enumerates  the  indications  of  anaesthesia 
of  peripheral  or  central  origin  : — 

"  «.  The  more  the  anaesthesia  is  confined  to  single  filaments  of  the  tri- 
geminus,  the  more  peripheral  the  seat  of  the  cause  will  be  found  to  be. 

"  b.  If  the  loss  of  sensation  affects  a  portion  of  the  facial  surface,  to- 
gether with  the  corresponding  facial  cavity,  the  disease  may  be  assumed 
to  involve  the  sensory  fibres  of  the  fifth  pair  before  they  separate  to  be 
distributed  to  their  respective  destinations;  in  other  words,  a  main  divi- 
sion must  be  affected  before  or  after  its  passage  through  the  cranium. 

"  c.  When  the  entire  sensory  tract  of  the  fifth  nerve  has  lost  its  power, 
and  there  are  at  the  same  time  derangements  of  the  nutritive  functions  in 
the  affected  parts,  the  Gasserian  ganglion,  or  the  nerve  in  its  immediate 
vicinity,  is  the  seat  of  the  disease. 

"  d.  If  the  anaesthesia  of  the  fifth  nerve  is  complicated  with  disturbed 
functions  of  adjoining  cerebral  nerves,  it  may  be  assumed  that  the  cause 
is  seated  at  the  base  of  the  brain." 

Prognosis — It  is  by  no  means  bad  after  the  cause  is  removed. 
Anesthesia  from  pressure  is  rapidly  restored,  provided  the  mechanical 
injury  be  not  too  great.  If  there  be  division  of  the  nerve,  the  process  of 
reparation,  which  rarely  extends  for  more  than  a  few  months,  is  followed  by 
a  healthy  return.  With  syphilis  and  the  skin  diseases  the  case  is  different. 

Treatment — Electricity  offers  the  best  mode  of  relief.  The  wire 
brush  and  fanidic  current  are  to  be  employed  every  day;  and  at  the  same 
time  applications  of  alternate  heat  and  cold,  friction  and  massage,  are 
useful  adjuvants. 


1  Ronibcrg.     A  Manual  of  the  Nervous  Diseases  of  Man.     Sydenham  trans. 
vol.  i.  p.  213,  et  xffj. 


TUMORS    OP    NERVES.  451 

TUMORS  OF  NERVES. 

Synonym  — Neuromata. 

A  nerve  may  be  the  seat  of  either  a  syphilitic,  cancerous,  sarcomatous, 
myxomatous,  or  other  growth  which  may  involve  or  destroy  some  point  in 
its  continuity,  or  form  as  a  benignant  tumor  at  its  point  of  severance. 

Very  little  has  been  written  upon  this  important  subject ;  but  among  the 
most  valuable  contributions  to  the  literature  of  nerve-tumors  is  an  excel- 
lent thesis  by  Foucault,1  and  various  scattered  articles  by  Verneuil,2  Le 
Fort,  Axenfeld,  Roger,  and  others. 

Nerve-tumors  may  be  classified  as  neuromata  (nervous  neuroma  of 
Weber)  and  medullary  nerve-tumors,  which  involve  the  nervous  structure 
itself;  and  pseudo-neuromata,  which  include  the  fibromata,  myxomata, 
epithelioma,  as  well  as  cysts  and  tumors  of  a  like  character. 

Medullary  or  ganglion  tumors  are  quite  rare,  and  are  of  a  hyperplastic 
character.  Lebert3  described  a  neuroma  of  the  superior  cervical  ganglion, 
in  which  all  traces  of  true  nervous  matter  had  disappeared,  and  naught 
remained  but  a  fibro-fatty  structure.  Robin4  has  found  a  neuroma  in  the 
solar  plexus,  and  Virchow  has  also  brought  forward  examples. 

Neuroma  of  nervous  fasciculi  (nevromes  fascicules)  include  the  little 
painful  tumors  which  are  met  with  after  amputation,  which  give  rise  to 
stump  neuralgia,  and  attain  the  size  often  of  a  hazel-nut.  Dupuytren,5 
Cornil6  and  Ranvier,  Axmann7  and  Weissman,8  have  all  described  their 
appearance  and  structure,  which  is  fibrous  and  hard,  and  the  nerve-tubes 
are  tortuous  and  interlaced. 

The  pseudo-neuromata  are  of  many  varieties.  They  are  developed 
usually  in  the  course  of  the  nerve,  and  the  neurilemma  is  thickened,  and 
should  the  nerve  be  cut  across,  a  white  or  yellowish  hardening  will  be 
presented.  Should  the  tumor  be  fibrous,  the  peculiar  microscopical  appear- 
ance may  be  observed.  Fibromata  rarely  exceed  the  size  of  an  almond; 
but  when  there  is  any  fluid  found,  as  in  the  case  of  fibro-cystic  tumors, 
the  volume  of  the  enlargement  may  be  much  greater. 

The  accompanying  cut  represents  a  sarcoma  of  the  ulnar  nerve,  and  was 
observed  by  Demarquay  at  the  Maison  Municipale  de  Sant6. 

Nerve-tumors  prefer  the  nerves  of  the  upper  and  lower  extremities,  and 
in  the  leg  the  posterior  tibial  nerve  seems  to  be  a  common  site.  It  is  not 
uncommon  to  find  a  great  many  tumors  of  this  kind  existing  at  the  same 
time.  In  one  case  reported  by  Foucault,  1400  of  them  were  found,  but 

1  Stir  les  Tumeurs  des  Nerves  Mixtes,  Thfese,  1872. 

2  Arch,  de  Med.,  tome  xviii.  1861. 

3  Mem.  de  la  Soc.  de  Clin.  1853,  3  fasc. 

4  Comptes  Rendus  de  la  Soc.  de  Biol.,  1854. 

5  Loc.  cit. 

6  Memoires  de  la  Soc.  Biologic,  t.  v.,  3d  s6rie,  18G3. 

7  Beitz,  zur.  mikr.  Anat.  du  Ganglion  Nervensystems,  Berlin,  1853, 

8  Ueber  Xerveunenbildung  (Zeitschr.  f.  Ratioimelle  Med.  1859). 


452 


DISEASES    OP    THE    PERIPHERAL    NERVES. 


Fig.  51. 


this  is  exceptional,  and  it  is  probable  that  multiple  neuromata  are  more 
frequently  found  in  patients  who  are  of  the  cancerous,  syphilitic,  or  some 
other  diathesis.  Very  often  these  growths,  the  result  of  injury,  are 
subcutaneous.  In  one  of  my  cases  the  growth  wus  found  at  the  dhow  ;i( 
the  exposed  site  of  the  ulnar  nerve,  and  its  origin  followed  a  blow  upon 
that  part. 

Pain,  as  I  have  said,  is  the  prominent  symptom  of  such  growths.  This 
pain  may  appear  upon  the  tumor,  but  usually  follows  its 
establishment.  It  may  be  localized  or  diffused,  or  may 
be  provoked  by  pressure  on  the  spot  or  spots  which  mark 
the  site  of  the  growth;  for,  when  the  tumors  are  multi- 
ple, of  course  the  sensory  troubles  are  equally  numerous. 
The  pain  may  radiate  from  the  tumor,  or  may  dart  down 
or  up  the  affected  nerve.  It  is  not  so  intense  with  fibro- 
mata, syphilomata,  or  sarcomata,  or  when  the  tumor  is 
composed  mainly  of  true  nervous  tissue,  as  is  the  case  in 
stump  growths,  and  in  these  examples  it  is  productive  of 
severe  neuralgia  of  a  reflex  character.  Spasms,  perma- 
nent muscular  contractions,  and  sometimes  a  peculiar  con- 
striction of  the  thorax  of  a  tetanic  nature,  with  epilepti- 
form  seizure  and  centripetal  pain,  are  indicative  of 
certain  reflex  disturbances. 

Treatment — Operation  seems  to  offer  the  only  hope 
of  relief,  and  in  stump  neuromata  re-amputation  is  often- 
times necessary.  It  will  be  found  necessary  to  deeply 
anaesthetize  the  patient,  as  the  sensibility  is  so  morbidly 
active  that  ordinary  anaesthesia  is  insufficient.  The  re- 
moval of  a  considerable  piece  of  the  nerve  is  advisable, 
for  it  is  not  rare  to  find  considerable  infiltration  or  deposit 
in  its  substance  for  some  distance  from  the  actual  growth. 
In  syphilis,  mercurials  and  the  iodides  offer  some  show 
of  relief,  and  these  are  the  only  remedies  when  the 
growth  is  deep-seated.  Legrand1  and  others  have  recom- 
mended caustic  applications  in  superficial  regions,  and 
Siebold  pere  removed  a  tumor  in  this  way  from  the  an- 
terior tibial  nerve.  The  operation  is  rather  severe,  and 
is  attended  with  doubtful  success. 


Snrcoinatoug    Neu- 
r.'init.    (Foucault.) 


Gaz.  Med.,  Compte-Rendus.de  1'Acad.  des  Sciences,  1858. 


FACIAL    PARALYSIS.  453 


CHAPTER    XYII. 

DISEASES  OF  THE  PERIPHERAL  NERVES  (CONTINUED). 


LOCAL  PARALYSES. 


FACIAL  PARALYSIS. 

Synonyms — Bell's  paralysis  ;  Histrionic  paralysis. 

Facial  paralysis  may  be  either  double  or  single,  but  is  more  often  the 
latter ;  and  it  may  depend  upon  a  lesion  of  a  peripheral  kind,  or  one  that 
may  be  seated  in  the  temporal  bone,  or  at  any  point  in  its  course  within 
the  cranial  cavity,  or  else  at  its  origin. 

The  bilateral  form  is  rare,  and  is  always  the  result  of  a  central  lesion ; 
but  the  peripheral  form  is  unilateral,  and  is  a  very  common  affection. 

Symptoms — The  patient,  after  exposure,  may  suddenly  be  attacked ; 
and  the  first  intimation  he  generally  has  is  in  the  morning,  when  he  arises. 
He  then  finds  his  face  to  be  all  awry,  and  his  appearance  is  absurd  to  the 
last  degree ;  one  side  being  drawn  up,  while  the  other  is  immobile, 
as  the  muscles  of  expression  are  powerless.  If  he  laughs,  the  contor- 
tion is  more  marked,  and  if  he  attempts  to  whistle  he  will  find  that  he 
is  utterly  unable  to  do  so.  The  corner  of  the  mouth  on  the  sound  side  is 
drawn  up,  and  the  furrow  at  the  angle  of  the  nose  is  more  marked  than 
natural.  The  opposite  side  of  the  face  is  smooth;  and,  in  the  passive  state, 
the  muscles  seem  to  sag  heavily  downwards.  It  is  impossible  for  him  to 
corrugate  his  eyebrows  ;  and  the  eyelids  of  the  paralyzed  side  cannot  be 
closed,  so  that  dust  and  foreign  substances  collect,  producing  irritation  and 
discomfort.  This  is  due  to  the  paralysis  of  the  orbicularis,  and  at  the 
same  time  the  levator  palpebrarum  contracts  and  keeps  the  eyeball  exposed. 
The  individual  is  unable  to  blow  out  a  candle,  and  articulation  is  inter- 
fered with  to  a  slight  degree.  Should  he  be  an  old  man,  any  wrinkles  or 
furrows  that  may  have  existed  on  the  paralyzed  side  are  effectually  effaced, 
and  give  that  part  a  most  ghastly  appearance.  Considerable  discomfort 
results  from  the  insufficiency  of  the  lower  lid,  so  that  the  tears,  instead  of 
being  conducted  to  the  lachrymal  canal,  find  their  way  over  the  cheek. 

If  the  lesion  be  situated  within  the  temporal  bone  or  the  cranium,  a 
much  more  extensive  paralysis  may  result.  This  is  indicated  by  a  loss  of 
power  of  the  muscles  of  the  palate,  uvula,  and  other  parts  of  the  fauces. 

When  the  patient  opens  his  mouth,  the  palatine  arch  will  be  found  to  be 
altered,  the  anterior  pillars  of  the  fauces  being  shorter,  so  that  one  side 


454  DISEASES   OP    THE    PERIPHERAL    NERVES. 

falls  lower  than  the  other.1  The  uvula  will  also  be  found  to  be  arched, 
the  concavity  looking  towards  the  sound  side.  The  tongue  will  then  alx> 
be  paralyzed,  so  that  its  surface  is  smooth  ;  and  there  may  be  a  dryness  of 
the  mouth,  which  results  from  diminished  secretion  of  saliva.  Should 
the  portio  mollis  be  affected,  there  may  be,  in  addition,  deafness.  If  the 
third  nerve  be  affected,  as  it  sometimes  is,  of  course  ptosis  with  dilated 
pupil  and  paralysis  of  the  recti  will  result. 

Roux,1  who  was  panilyzed  in  this  manner,  perceived  a  metallic  taste  in 
the  right  side  of  the  tongue. 

Should  the  paralysis  be  bilateral,  the  patient's  features  will  denote  an 
entire  lack  of  expression,  and  there  is  not  the  slightest  evidence  of  any 
emotional  excitement  expressed,  even  should  the  patient  be  agitated  by 
the  most  intense  pleasure  or  the  deepest  grief.  The  muscles  are  flabby, 
and  the  face  seems  more  like  a  mask  than  what  it  really  is  ;  and,  as  is  the 
case  in  advanced  progressive  muscular  atrophy,  the  only  animated  features 
are  the  eyes. 

Romberg8  describes  the  appearance  of  a  patient  in  these  words  :  "  In  a 
girl  of  1C,  in  Dupuytren's  Clinique,  who  was  affected  with  bilateral  para- 
lysis, there  was  no  distortion,  but  a  pendulousness  and  entire  absence  of 
motion  was  perceptible  in  all  the  features.  The  eyelids  only  closed  half, 
the  lips  stood  apart,  and  played  backwards  and  forwards  from  the  impulse 
of  respiration.  The  expressive  countenance  bore  a  serious  character, 
which  contrasted  forcibly  with  the  patient's  frame  of  mind.  She  \vas 
heard  to  laugh  aloud,  but  the  laugh  appeared  to  come  from  behind  a  mask." 
Sensation  is  not  usually  impaired. 

Causes. — The  peripheral  form  of  paralysis  may  follow  exposure  to 
cold,  rheumatic  exudation,  and  injuries  of  various  kinds.  A  cause  which 
is  frequently  observed  is  the  chilling  of  the  face  by  a  blast  of  cold  wind; 
and  the  frequency  of  this  cause  has  led  to  the  adoption  by  the  French 
writers  of  the  term,  "  Coup  de  vent."  I  have  met  with  many  cases  in 
which  the  paralysis  took  place  after  a  railroad  journey,  the  individual 
having  sat  by  an  open  window. 

In  one  instance  the  patient,  who  was  a  young  lady,  had  been  dancing 
violently,  and  had  afterwards  gone  into  a  damp  conservatory  to  cool  off; 
the  palsy  was  shortly  afterwards  noticed. 

Rheumatic  exudations  may  produce  pressure  upon  some  of  the  nerve- 
twigs,  or  an  attack  of  parotitis  may  result  in  pressure  upon  the  cervico- 

1  Hughlings  Jackson  (London  Lancet,  Jan.  16,  1875)  does  not  consider  that 
deviation  of  the  palate  occurs  in  uncomplicated  disease  of  the  portio  dura,  and  he 
does  not  believe  deviation  of  the  uvula  to  be  uncommon  in  healthy   people. 
Troltseh  says  that  the  levator  palati  is  supplied  by  the  vagus,  which  explains 
the   phenomena  witnessed  by  Jackson,  viz.,  marked  palsy  of  one  side  of  the 
palate,  with  palsy  of  the  vocal  cord  on  the  same  side,  as  a  result  of  intracranial 
disease.     This  case,  however,  is  exceptional. 

2  Descot.     Diss.  sur  les  Affections  locales  des  Nerfs,  Paris,  1825,  p.  S31. 
8  Op.  cit.,  vol.  ii.  p.  2G8. 


FACIAL    PARALYSIS.  455 

facial  branch.  Injuries  of  the  nerve,  whether  such  as  follow  coarse  trau- 
matism  or  accidental  section  of  the  nerve  during  a  surgical  operation,  are 
sometimes  the  cause  of  the  paralysis. 

Weir  Mitchell  relates  several  cases  of  this  kind.  Three  of  these 
(Cases  61,  G2,  and  G3)  followed  gunshot  wounds.1  In  one  the  portio  dura 
of  the  left  side  was  injured,  and  as  a  consequence  there  were  facial  palsy, 
impaired  sj>eech,  and  loss  of  gustation.  Hearing  was  impaired  from 
shock  transmitted  to  the  auditory  nerve.  Sir  Charles  BelP  divided  the 
facial  in  removing  a  tumor,  and  other  cases  are  reported  by  various 
surgeons. 

Carious  disease,  as  well  as  fractures  of  the  temporal  bone,  often  pro- 
duces paralysis,  either  by  pressure,  by  the  products  of  inflammation,  or  by 
direct  contusion. 

Tumors  and  various  aural  growths  are  occasionally  causes  of  this  second 
form  of  facial  palsy;  and  Romberg3  reports  a  case,  seen  by  Henle,  in  which 
a  tuberculous  deposit  was  found  beneath  the  middle  lobe  of  the  brain,  with 
destruction  of  the  petrous  portion  of  the  temporal  bone  ;  and  Froriep4  also 
found  a  deposit  of  tuberculous  matter  in  the  Fallopian  canal,  with  caries 
of  the  petrous  portion  of  the  bone. 

Degeneration,  exudation,  and  tumor  in  or  near  the  pons  may  also  be 
the  cause  of  the  deep  form. 

The  following  case  is  an  example  of  deep-seated  paralysis,  evidently 
dependent  upon  aural  disease. 

Samuel  M.,  aged  27  ;  United  States,  canal  boatman  ;  came  to  me  July 
3,  1876.  Three  days  before  the  first  visit,  after  exposure  while  washing 
the  decks  of  his  boat,  he  became  paralyzed.  He  had  had  earache  before 
for  several  days,  but  did  not  consider  it  of  sufficient  moment  to  quit  work ; 
and  his  first  intimation  of  trouble  was  the  discomfort  produced  by  par- 
ticles of  dust  which  blew  in  his  eye.  He  could  not  close  his  left  eye,  and 
on  looking  in  the  glass  he  discovered  the  paralysis.  There  was  no  pain, 
nor  any  subjective  sensation  of  any  kind.  He  found  that  he  could  not 
laugh,  nor  blow  his  nose,  and  when  he  attempted  the  latter  "  the  wind 
came  out  of  his  mouth."  When  I  saw  him  there  was  paralysis  of  both 
branches  of  the  seventh  nerve.  Hearing  was  very  imperfect,  and  he  could 
not  count  the  ticks  when  the  watch  was  pressed  to  the  left  ear.  The  left 
palatine  arch  was  obliterated,  and  he  could  not  fully  protrude  the  tongue, 
which  was  quite  dry.  The  left  side  of  the  face  is  quite  flat,  and  the  mus- 
cles of  the  other  side  act  to  such  a  degree  as  to  draw  up  the  right  corner 
of  the  mouth,  producing  the  characteristic  deformity.  When  he  opens 
his  mouth,  the  orifice  is  unsymmetrical.  He  cannot  whistle  or  expecto- 
rate. He  cannot  close  the  left  eye,  but  when  he  attempts  to  do  so  the  ball 
is  drawn  upwards,  so  that  the  sclerotic  is  shown  to  a  great  extent.  Con- 
tractility to  both  currents  fair;  mediate  and  immediate  galvanization  are  fol- 
lowed by  muscular  response.  He  has  some  earache.  When  the  electrode 

1  Injuries  of  Nerves,  etc.,  p.  392,  et  seq. 

2  The  Nervous  System  of  the  Human  Body,  3d  ed.,  1836,   p.  56. 

3  Romberg,  op.  cit.,  p.  272. 

4  Massalien,  Diss.  Inaugur.  de  Nervo  Faeiali,  Berolin.  1836. 


456  DISEASES   OF    THE    PERIPHERAL    NERVES. 

is  passed  over  the  superficial  points  of  the  fifth,  there  is  decided  pain,  no 
anaesthesia  ;  force  of  masseter  muscles  tested  by  putting  the  dynamometer 
bulb  between  the  teeth  and  interposing  two  pieces  of  wood ;  no  loss  of 
power  as  compared  with  my  own  attempts.  Tympanum  red  ;  and  I  infer 
that  there  is  middle  ear  disease.  R.  Potass,  iodid.  and  syringing  ear  with 
warm  water. 

July  6.  Has  had  intense  pain  in  the  left  ear,  throbbing  and  pains  which 
radiate  over  the  head.  Pressure  over  mastoid  process  gives  great  distress, 
as  does  electrization.  Leeching  to  inner  tragus. 

9<A.  Says  that  there  was  a  discharge  of  pus  last  night.  After  syringing 
out  I  find  a  perforated  tympanum.  Stopped  iodide,  and  ordered  syringing 
with  warm  water  and  glycerin. 

13th.  Discharge  from  ear  much  less.  Used  iodoform  powder  locally. 
Muscles  do  not  respond  so  well  to  either  current.  Iodide  renewed. 

17th.  No  response  to  current.     Faradized  nevertheless. 

19M,  21st,  23d,  '21th.  Used  iodoform.  Aural  disease  almost  well,  but 
patient  still  deaf.  Muscles  still  inactive. 

30th.  Tested  sense  of  taste,  and  find  it  markedly  affected  ;  his  tongue 
seems  quite  smooth.  He  has  had  from  the  first  some  clumsiness  in  speech. 

Oct.  1877.  There  has  been  very  slight  improvement  since  the  last 
entry.  The  facial  deformity  is  not  so  great.  He  is  still  deaf.  His  speech 
is  clear,  but  he  cannot  whistle  as  yet.  The  muscles  do  not  respond  to  the 
currents.  He  suffers  great  annoyance  from  the  accumulation  of  saliva, 
and  when  he  expectorates  he  soils  his  clothing. 

Pathology. — The  anatomical  distribution  of  the  facial  nerve  and  its 
connection  with  other  nerves  may  be  referred  to  in  illustration  of  the  pa- 
thology of  the  affection.  Beginning  externally,  we  find  that  the  facial 
nerve  supplies  the  muscles  of  the  face,  the  malar  branches  innervating  tin* 
orbicular  muscles  of  the  eyes ;  that  the  infra-orbital  supply  the  buccina- 
tor and  orbicularis  muscles,  and  the  levator  labii  superioris  aloeque  nasi 
muscles;  while  the  cervico-facial  division  of  the  nerve  passes  through  the 
parotid  gland,  and  supplies  the  muscles  of  the  mouth  and  lower  jaw ;  conse- 
quently a  lesion  of  any  of  these  branches,  or  of  the  main  trunk  at  its  exit 
from  the  stylo-mastoid  foramen,  would  be  followed  simply  by  paresis  of 
the  facial  muscles.  Should  the  lesion  take  place  in  the  aqueductus  Fallopii, 
or  behind  the  geniculate  ganglion,  we  would  find  as  a  consequence  paralysis 
of  the  muscles  of  the  face,  the  tongue,  through  paralysis  of  the  chorda 
tympani,  and  paralysis  of  the  palate  muscles,  through  paralysis  of  the  larger 
superficial  petrosal  nerve,  which  runs  from  the  geniculate  ganglion  to  the 
spheno-palatine  ganglion.  Deep  lesions  may  involve  the  third  nerve,  and 
perhaps  the  sixth.  The  lesions  and  their  results  may  be  thus  arranged : — 


FACIAL    PARALYSIS.  457 

Paralysis  of  the  Seventh  Nerve. 

EXTERNAL  THIRD.  MIDDLE  THIRD.  INTERNAL  THIRD. 

Facial  Branches.  Petrosal  nerves,  Auditory         Possibly  lesion  involves 

(Portio  mollis),  Chorda      the   3d  and    6th    nerves, 

Paralysis  of  the  Tympani.  and  then  besides  all  of  the 

Orbicularis  palpebrarum,  foregoing   there   may   be 

Corrugator  supercilii,  Paralysis  of  all  the  fore-     paralysis   of   the   levator 

Levator  labii,  etc.,  going  as  well  as  lingualis,     palpebrse    and    the   recti 

Pyramidalis  nasi,  tensor  and   laxator  tym-     muscles. 

])iagastric,  pani,   levator  palati,  and 

Buccinator,  azygos  uvulae. 

Orbicularis  oris, 
Depressor  anguli  oris, 
Levator  labii  inf. 

Diagnosis — The  appearance  of  facial  paralysis  may  be  a  source  of 
alarm  to  the  individual,  who  is  ready  to  believe  it  a  feature  of  cerebral 
hemorrhage  or  deep  organic  trouble.  It  is  much  more  profound,  however, 
than  the  form  which  accompanies  cerebral  hemorrhage  ;  and  generally 
there  is  hemiplegia  of  the  extremities  in  the  latter  disease.  In  this  form 
it  is  impossible  for  the  patient  to  shut  the  affected  eye,  while  in  the  other 
disease  there  is  usually  no  difficulty  in  so  doing.  Sensation  is  also  affected 
in  the  paralysis  from  cerebral  hemorrhage,  and  it  is  not  unusual  to  find 
ptosis.  The  matter  of  importance,  however,  is  the  diagnosis  of  the  variety 
of  facial  palsy,  superficial  or  deep ;  and  we  may  avail  ourselves  of  elec- 
tricity in  settling  this  point. 

If  the  paralysis  be  peripheral,  the  muscles  retain  their  contractility  for 
several  weeks.  If,  on  the  contrary,  the  lesion  be  central,  or  in  a  nerve-trunk, 
they  lose  their  power  of  response  to  a  faradic  current  in  a  few  days,  and 
later  to  even  a  galvanic  current,  and  the  muscles  finally  become  atrophied. 
If  the  paralysis  be  due  to  bulbar  disease,  the  appearance  of  symptoms  in- 
dicating impairment  of  other  nerves  and  an  eventual  fatal  termination 
should  settle  the  nature  of  the  affection,  and  enable  us  to  make  a  prognosis. 
The  existence  of  carious  disease  and  its  indications,  the  complication  of 
deafness,  and  the  coexistence  of  indications  of  deep  trouble,  should  be 
all  taken  into  account. 

Prognosis The  prognosis  of  the  peripheral  form  of  the  disease  is 

very  good,  and  under  proper  treatment  the  paralyzed  muscles  may  be 
rapidly  restored.  There  is  generally  early  loss  of  muscular  contractility, 
which  only  the  galvanic  current  can  restore.  If  there  is  no  response  to 
electrical  excitement,  and  the  muscles  of  the  paralyzed  side  are  wasted  and 
contracted,  there  is  little  to  be  hoped  for.  I  consider  that  more  depends 
upon  the  early  adoption  of  electrical  treatment  than  anything  else ;  and  if 
there  be  a  delay  in  the  selection  of  remedies,  and  in  the  attempts  to  restore 
the  muscles  by  mechanical  support  and  electricity,  the  prognosis,  which 
may  have  been  favorable  in  the  beginning,  becomes  less  and  less  so,  the 
longer  action  is  delayed. 


458  DISEASES   OF    THE    PERIPHERAL    NERVES. 

Syphilis  is  a  favorable  element  if  the  paralysis  be  due  to  deep  lesions ; 
but,  if  it  be  caused  by  brain-tumors,  exudations,  or  degeneration,  there  is 
scarcely  any  hope. 

Treatment. — It  is  necessary  in  this  disease  to  direct  the  treatment 
not  only  to  the  cause,  when  one  can  be  found,  but  also  to  the  restoration 
of  the  paralyzed  muscles. 

Should  rheumatism  exist,  we  are  to  employ  colchicum  and  iodide  of 
potassium  ;  if  syphilis,  the  specifics  which  are  at  our  disposal ;  and  if  there 
be  caries,  we  are  to  improve  the  patient's  general  health  by  nourishment 
and  stimulants,  and  to  apply  such  local  treatment  as  may  seem  proper. 
The  medicaments  which  will  be  found  to  be  of  service  for  the  direct 
treatment  of  the  paralysis  are  strychnia,  iron,  and  quinine.  Electricity  is 
of  great  service  ;  and  we  may  begin  with  the  galvanic  current  and  use  the 
farad ic  as  soon  as  it  can  produce  contractions.  The  negative  pole  of  the 
galvanic  battery  should  be  placed  behind  the  ear,  and  the  positive  pole 
passed  over  the  different  facial  muscles.  The  glass  "bain  electrique" 
should  be  applied  to  the  eye,  so  that  the  orbicularis  shall  be  brought  under 
the  influence  of  the  current. 

The  mechanical  treatment  of  facial  paralysis  has  been  advocated  by 
Detmold,  and  with  admirable  results.  A  piece  of  tin  wire  is  bent  at  both 
ends  (Fig.  52),  and  one  end  is  passed  over  the  ear  and  the  other  hooked  in 
the  angle  of  the  mouth,  so  that  the  muscles  of  the  paralyzed  side  shall  be 
supported.  In  several  of  Detmold's  cases  it  was  found  to  work  exceed- 
ingly well. 

Fig.  52. 


Wire  Hook  for  the  Treatment  of  Facial  Paraljsis. 

This  apparatus  may  be  worn  at  night  or  during  the  day,  and  does  not 
give  the  patient  any  discomfort  whatever. 

Dr.  Van  Bibber  has  suggested,  in  the  treatment  of  ptosis,  the  use  of  a 
small  strip  of  court  plaster,  which  is  affixed  to  the  upper  lid  and  to  the 
forehead  above. 


FACIAL    PARALYSIS.  459 

I  may  append  a  case  of  facial  palsy  of  a  syphilitic  nature  cured  by 
electricity  in  a  remarkably  short  space  of  time. 

W.  O.  I.,  30  years;  United  States,  boatman.  Previous  history:  He 
has  never  been  seriously  ill,  but  ten  years  ago  he  had  a  chancre,  followed 
by  marked  secondary  symptoms.  The  only  other  ailment  was  a  severe 
attack  of  rheumatism,  occurring  a  year  before.  This  was  undoubtedly  a 
secondary  symptom.  His  present  difficulty  began  three  months  ago.  At 
night  he  was  disturbed  by  intense  cephalic  pains,  dizziness,  and  disordered 
vision.  For  several  days  the  pains  were  steady  and  most  violent  under 
either  temple  ;  he  was  also  annoyed  by  post-aural  pains.  He  then  found 
that  his  hearing  was  becoming  less  acute,  till  the  lesion  finally  occurred. 
This  took  place  towards  the  latter  part  of  July,  1870.  He  awoke  in  the 
morning  and  felt  a  pain  in  the  head,  attended  by  swelling  and  puffiness  in 
the  face.  His  attention  was  called  by  several  of  his  associates  to  the 
"  crookedness"  of  his  face.  He  looked  in  the  glass,  and  saw  the  drooping 
of  the  left  side  of  the  face,  with  complete  paralysis  of  the  muscles  at  the 
corner  of  the  mouth  ;  then  followed  total  loss  of  hearing,  and  he  could  not 
appreciate  the  loudest  noises  when  the  sound  ear  was  closed.  The 
paralysis  increased  every  day. 

A  few  days  after  this  the  eyelid  drooped,  and  he  found  it  impossible  to 
open  or  completely  shut  the  eye.  It  became  congested  and  irritated,  and 
he  experienced  a  burning  sensation,  with  photophobia.  His  condition 
grew  gradually  worse,  till  he  was  compelled  to  leave  his  employment  and 
seek  medical  aid.  He  never  had  had  otorrhoea  or  ear  affections  of  any 
kind,  nor  had  been  paralyzed.  His  habits  were  good,  and  his  hereditary 
history  favorable.  When  he  applied  to  me,  I  found  paralysis  of  the  entire 
seventh  nerve,  motor  ocularis,  and  disturbance  of  the  sympathetic  of  the 
eye.  There  was  no  appreciable  power  in  the  orbicularis  oris,  levator 
labii  superioris  et  alaeque  nasi,  or  other  muscles.  He  could  hardly  insert 
the  finger  in  the  mouth  without  pulling  down  the  jaw  with  the  other 
hand.  He  experienced  mastication  and  deglutition  from  involvement  of 
the  left  side  of  the  tongue,  which,  when  protruded,  inclined  to  the  right 
side.  With  this  there  was  indistinct  articulation,  and  I  was  led  to  infer 
paralysis  of  the  lingualis  muscle.  From  the  patient's  previous  history  I 
was  led  to  suppose  that  syphilis  was  the  primary  cause  of  the  trouble,  and, 
from  the  depth  of  the  lesion,  that  the  seventh  nerve  was  paralyzed  at  a 
point  above  its  division.  From  the  specific  features  of  his  case  I  deemed 
the  iodide  of  potassium  to  be  the  best  remedy,  and  he  was  therefore  put 
upon  grs.  v  thrice  daily.  Hypodermic  injections  of  strychnia  and  atropia 
(_i^  of  a  grain  of  the  former  to  ^  of  the  latter)  did  much  good  in  relieving 
the"  severe  cephalalgia.  Localized  galvanization  was  resorted  to,  and  both 
the  primary  and  secondary  currents  used.  After  the  nerve  and  its 
branches  had  been  pencilled  over  with  stick  caustic,  one  electrode  was 
applied  to  the  ramifications  of  the  nerve,  while  the  other  was  placed  over 
the  mastoid  process.  So  successful  was  this  treatment  that  after  a  daily 
stance  lasting  twenty  minutes,  in  three  weeks  the  patient's  face  was  much 
more  symmetrical,  and  the  act  of  mastication  improved.  The  pains  like- 
wise disappeared  under  the  same  current.  Occasional  directions  of  this 
and  the  faradic  current  over  the  eyelid  did  much  toward  the  improvement 
of  sight. 

It  now  occurred  to  me  that  Matteucci's  experiment  on  the  ear  i 
followed  by  gratifying  results  ;  so  its  cavity  was  filled  with  water,  and  one 
of  the  battery-wires,  finely  covered  with  sponge,  was  gently  introduced 


460  DISEASES    OF    THE    PERIPHERAL    NERVES. 

into  the  external  meatus.  After  four  weeks  his  hearing  was  so  markedly 
improved  that  he  easily  distinguished  loud  voices  \yhen  the  sound  ear  was 
closed. 

November  1 2  (seven  weeks  after  commencement  of  treatment).  During 
the  application  of  the  current  the  face  resumed  its  expression,  and  IH  wa- 
able  to  close  his  eye  completely.  He  is  greatly  improved  ;  injections  dis- 
continued. He  has  almost  complete  control  over  the  levator  palpebrae — 
this  is  marked  in  the  morning ;  articulation  good. 

28M.  Has  now  taken  the  battery  for  nearly  ten  weeks,  and  is  about 
to  discontinue  treatment.  The  face  is  perfectly  symmetrical,  and  the 
hearing  nearly  as  perfect  as  ever.  The  only  remaining  disfigurement  is  u 
slight  drooping  of  the  eyelid  on  the  affected  side ;  appetite  good,  and, 
though  emaciated  at  first,  he  has  now  completely  regained  his  former  good 
condition. 


TRAUMATIC  PARALYSIS. 

Under  this  head  I  propose  to  speak  of  those  forms  of  lost  power  de- 
pendent upon  partial  or  complete  nerve-section,  or  pressure  made  upon  a 
nerve  in  its  course,  such  as  is  often  seen  in  a  familiar  form  known  as 
decubitus  paralysis,  as  well  as  in  the  loss  of  motility  produced  by  cold  or 
other  influences  which  may  affect  the  ramifications  at  the  peripheral  end 
of  a  nerve-trunk.  There  is  no  regularity  either  in  the  form  of  invasion, 
the  extent  of  the  paralysis,  or  its  locality.  Suffice  it  te  say,  that  both  upper 
and  lower  extremities  may  be  affected,  the  upper  especially,  and  that  such 
paralysis  is  not  bilateral.  The  liability  of  the  upper  extremities  to  this 
accident  is  probably  explained  by  their  use  in  many  of  the  necessary 
actions  of  everyday  life.  These  forms  of  paralysis  may  be  divided  into 
three  groups :  (1)  Paralysis  following  section  or  destruction  of  a  nerve- 
trunk  or  its  tranches;  (2)  Paralysis  following  pressure;  (3)  Paralysis 
following  cold,  or  general  disease. 

Division  of  a  Nerve-trunk — If  the  section  be  complete,  the  paralysis 
will  be  equally  complete  and  immediate.  There  is  likely  to  be,  in  addi- 
tion to  lost  sensation  and  motion  in  the  muscle  supplied  by  the  nerve, 
various  trophic  defects,  which  may  consist  in  exfoliation  of  the  skin, 
and  in  changes  in  the  condition  of  the  nails,  which  become  curved,  crenated, 
and  deformed  ;  and  sometimes  eruptions.  The  loss  of  motion,  of  course, 
will  depend  upon  the  importance  of  the  group  of  muscles  supplied  by  the 
nerve  ;  and  it  does  not  follow,  by  any  means,  that  the  member  is  utterly 
useless,  as  some  muscles  may  escape  the  paralysis.  Should  suppuration 
and  inflammation  occur  at  the  wound,  there  may  be  various  disturbances 
of  sensation,  and  also  lowered  temperature  in  the  paralyzed  side. 

Contusions  and  Punctured  Wounds — The  injuries  produced  by  kicks, 
or  direct  violence,  when  the  skin  is  not  broken,  are  very  commonly  fol- 
lowed by  traumatic  paralysis.  These  are  likely  to  occur  when  the  nerve 
rests  upon  some  bony  prominence,  and  when  there  is  no  muscular  or 
other  cushion  to  make  the  blow  less  slight.  I  can  recall  cases  of  this 


TRAUMATIC    PARALYSIS.  461 

kind,  one  in  particular,  where  the  individual  fell  in  the  street,  striking 
his  elbow  upon  a  projecting  stone.  There  were  no  immediate  symptoms 
except  a  tingling  and  sharp  pain,  but  in  a  few  days  there  was  loss  of 
power,  and  some  hypercesthesia  of  the  forearm. 

The  experience  of  surgeons  furnishes  us  with  numerous  examples  of 
peripheral  paralysis  from  dislocation.  Dr.  S.  G.  Webber,1  of  Boston,  has 
brought  forward  several  very  interesting  cases  of  this  variety,  with  disloca- 
tion of  the  humerus ;  and  Onimus  and  Legros3  a  case  which  Webber  pre- 
sents in  his  article  to  illustrate  a  form  of  paralysis  following  dislocation  of 
the  femur : — 

"A  man,  forty-six  years  of  age,  suffered  an  ilio-ischiatic  dislocation  of 
the  femur,  which  was  produced  by  violence  exerted  by  falling  rocks  and 
earth.  Severe  pain,  anaesthesia,  and  immobility  of  the  leg  existed  at  first, 
but  the  pain  subsequently  disappeared,  and  the  anaesthesia  remained. 
After  an  attack  of  facial  erysipelas  the  pain  in  the  legs  returned.  Five 
months  later  the  left  leg  was  found  to  be  cold  and  smaller  than  the  other, 
and  oedematous  about  the  tibio-tarsal  joint.  The  leg  could  be  flexed  and 
raised,  but  the  foot  could  not  be  raised  nor  the  toes  extended.  Sensation 
was  diminished,  as  was  electro-muscular  contractility,  especially  in  the 
flexors  and  extensors  of  the  leg,  the  muscles  of  the  calf  and  the  peronei,  as 
well  as  the  tibialis  anticus  and  extensor  communis." 

In  Webber's  case  of  paralysis  following  dislocation  of  the  humerus,  the 
biceps  and  deltoid  were  most  affected,  and  there  was  anaesthesia  over  the 
deltoid. 

J.  S.  came  to  the  N.  Y.  State  Hospital  for  Disease  of  the  Nervous  Sys- 
tem, June  9,  1871,  with  the  following  history:  During  an  altercation 
with  a  fellow-laborer  he  was  thrown  off  a  scaffold,  and  dragged  by  his 
right  arm  for  some  distance.  When  he  arose  he  found  that  the  whole 
arm  was  very  painful,  and  a  few  mornings  afterwards  the  right  wrist  be- 
came very  weak,  and  he  was  unable  to  grasp  any  object  or  move  his 
fingers.  Sensation  was  unimpaired. 

Nerve-injury  following  dislocation  is  not  always  the  same,  there  being  in 
some  cases  simply  pressure,  and  in  others  rupture  of  the  nerves  by  strain  ; 
and  of  course  the  prognosis  depends  much  upon  the  fact  whether  there  be 
simple  contusion  or  actual  laceration,  as  there  was  in  a  case  reported  by 
Hilton. 

Pressure  upon  nerves  may  be  made  by  the  products  of  inflammation, 
cicatrices,  callous  tumors,  or  by  improperly  arranged  splints,  or  the  press- 
ure of  a  crutch  or  some  hard  substance,  or  by  the  maintenance  of  a  con- 
strained position  for  an  extended  period.  The  production  of  a  periostitis 
may  exert  pressure  upon  a  nerve-trunk  in  some  bony  canal,  or  an  exuda- 
tion which  makes  compression  either  in  its  course  or  at  its  ramification. 
There  is  always  some  painful  indication  at  first,  and  occasionally  a  neu- 

1  Boston  Med.  and  Surg.  Journal,  Dec.  18,  1873. 

2  Trait6  d'  ElectricilS  MSdicale.  Paris,  1872. 


462  DISEASES   OF    THE    PERIPHERAL    NERVES. 

ritis,  after  which  the  loss  of  power  takes  place.  Movement  of  the  limb 
aggravates  this  pain,  or  pressure  over  the  nerve  has  the  same  effect. 
Pressure  from  a  cicatrix  is  quite  rare,  and  it  is  only  when  very  ext< -n-ivr 
contraction  of  the  cicatrix  occurs  that  any  such  condition  of  affairs  can 
exist.  So,  too,  is  pressure  from  callus  an  uncommon  cause  of  paralysis, 
and  but  a  few  cases  of  this  kind  have  been  mentioned. 

The  pressure  of  the  nerve  by  a  tumor  may  be  tirst  indicated  by  hyper- 
jesthesia,  and  secondarily  by  loss  of  motion  and  sensation,  and  the  dura- 
tion of  the  first  stage  depends  upon  the  site  of  the  tumor,  its  rapidity  of 
growth,  and  the  room  for  increase  in  size.  In  certain  situations  where 
there  are  bony  eminences  or  cavities,  and  where  there  is  no  room  for  ex- 
pansion of  the  mass  without  consequent  nerve-compression,  the  loss  of 
function  is  very  quickly  produced. 

By  far  the  most  familiar  form  of  peripheral  paralysis  is  that  which  fol- 
lows the  compression  of  nerves  during  the  continued  maintenance  of  a 
constrained  position,  the  nerve-trunk  being  pressed  against  some  bony 
eminence,  or  impinged  upon  by  some  tendon  or  muscular  mass.  The 
common  modes  of  onset  may  be  the  following :  The  patient  falls  asleep 
with  his  elbow  resting  upon  some  hard  substance,  and  awakens  to  find  his 
forearm  devoid  of  power.  The  following  are  examples  : — 

M.  P.  went  upon  a  spree,  and  when  he  became  sober  found  his  nrin 
numb  and  cold,  and  devoid  of  power ;  muscles  respond  to  faradic  current ; 
unable  to  force  dynamometer  column  to  6. 

T.  \V.,  four  years  ago,  fell  asleep  with  his  left  arm  under  his  hcnd  ; 
when  he  awoke  his  arm  was  numb  and  powerless.  Soon  after  formication 
appeared.  After  seven  months,  pain,  which  subsequently  became  parox- 
ysmal, began  in  the  arm,  coming  on  every  two  or  three  minutes.  Re- 
sponse only  to  galvanic  current. 

In  one  case,  reported  by  Webber,  the  paralysis  was  the  result  of  carry- 
ing a  basket  of  lemons,  pressure  being  made  on  the  radial  nerve. 

Mitchell1  speaks  of  paralysis  of  this  kind  resulting  from  the  most  simple 
causes.  In  one  case,  that  of  a  child,  pressure  was  made  by  a  string  pass- 
ing over  the  finger.  And  in  other  cases  reported  by  Brinton,"  it  was 
found  that  the  paralysis  followed  the  rough  use  of  a  pair  of  cord  handcuffs 
upon  a  prisoner  who  was  being  taken  to  the  police  station. 

The  use  of  the  forceps  is  occasionally  attended  by  paralysis  of  the 
facial  nerves,  the  blades  of  the  forceps  making  pressure  upon  the  portia 
dura.  In  these  cases  there  is  paralysis  of  the  facial  muscles,  an  inability 
to  nurse  owing  to  the  paralysis  of  the  orbicularis  oris,  but  no  palatine  loss  of 
power,  which  serves  to  diagnose  the  effects  from  the  form  due  to  Sntracra- 
nial  trouble.  The  mother  may  be  paralyzed  from  pressure  by  the  forceps 
exerted  upon  the  pelvic  nerves,  but  this  accident  is  an  extremely  rare  one. 

Accumulation  of  feces  produces  paralysis  generally  by  reflex  irritation, 
and  rarely  by  direct  pressure.  But  few  of  such  cases  have  been  reported, 

1  Op.  cit.,  p.  126.  «  U.  S.  San.  Com.  Reports. 


TRAUMATIC    PARALYSIS.  463 

and  of  these,  one  detailed  by  Portal1  is  of  great  interest,  from  the  fact  that 
spinal  curvature  favored  the  accumulation  of  feces  and  the  exertion  of 
pressure  upon  the  nerves  of  the  lumbar  plexus. 

Cold  or  malaria  may  also  be  causes  of  a  form  of  peripheral  paralysis. 
In  speaking  of  facial  palsy  I  have  alluded  to  the  variety  known  as  the 
"  Coup  de  vent."  This  sudden  origin  from  exposure  to  damp  and  wind  is, 
however,  much  more  rare  than  that  which  follows  intense  cold.  I  have 
had  several  cases  of  this  latter  kind  among  draymen,  sailors,  and  others 
who  have  been  obliged  to  work  for  a  protracted  period  in  an  exposed 
place.  There  is  at  first  a  numbness,  and  afterwards  a  complete  loss  of 
power,  which  may  be  bilateral. 

In  peripheral  paralysis  there  is  a  diminution  of  electro-muscular  con- 
tractility after  the  first  few  days,  and  if  there  be  complete  section  of  the 
nerve  this  susceptibility  to  electric  stimulation  is  lost,  first  to  the  faradic,  and 
at  the  end  of  a  week  or  two  to  galvanic  stimulation.  If  a  few  fibres 
remain  intact,  it  will  be  found  that  certain  muscles  are  unaffected,  and  of 
course  electrical  irritation  meets  with  a  ready  response.  Changes  of  color 
in  the  paralyzed  limbs  are  the  rule,  and  there  may  be  within  an  extensive 
blanching  or  patches  of  discoloration  dependent  upon  the  irregular  circula- 
tion. Analgesia  and  anaesthesia  generally  exist  in  some  degree,  while 
changes  of  temperature  are  not  so  readily  perceived  as  on  the  sound  side. 

As  the  nerve  is  restored,  electro-muscular  contractility  returns,  and  finally 
the  patient  is  enabled  to  produce  contraction  at  will. 

Arlong  and  Tripier2  have  alluded  to  the  rapid  return  of  sensibility  in 
distal  parts  after  nerve-section,  and  explain  it  by  the  theory  that  there 
are  anastomoses  between  the  severed  portions,  but  this  view  has  not  been 
generally  received. 

Diagnosis  and  Prognosis Progressive  muscular  atrophy  and 

cerebral  diseases  are  to  be  disposed  of,  and  if  we  see  the  case  after  the 
onset  we  may  be  deceived.  In  the  former  it  must  be  remembered  that 
there  are  fibrillary  contractions,  and  that  the  atrophy  precedes  the  paralysis. 
The  electro-muscular  contractility  is  also  preserved  for  some  time. 

In  cerebral  paralysis  the  electro-muscular  contractility  is  preserved,  and 
if  anything  exaggerated.  Cerebral  palsies  do  not  involve  such  exten- 

/» 

sive  sensory  impairment.  Spinal  paralyses  are  usually  bilateral,  a  fact 
which  distinguishes  them  from  peripheral  troubles. 

Mitchell  also  alludes  to  the  fact  pointed  out  on  a  previous  page,  that  in 
peripheral  palsies  there  is  none  of  the  delay  in  transmission  of  impression 
which  characterizes  either  spinal  or  cerebral  trouble. 

Westphal3  has  recently  reviewed  an  admirable  article  by  Vulpian,4  in 
which  he  refers  to  the  various  interesting  pathological  changes  which 
follow  division  of  spinal  nerves.  His  experiments  were  made  to  determine 


1  Cours  d' Anatomic  Medicale,  t.  iv.  p.  276,  quoted  by  Mitt-hell. 

2  Journal  de  T  Anatomic  et  Phys.,  etc.,  March  and  April,  1876. 

3  Ccntralblatt  fur  Med.  Wiss.,  July  13,  1872. 

4  Comptes  Reudus,  1872,  No.  15. 


464  DISEASES    OF    THE    PERIPHERAL    NERVES. 

the  muscle-changes  which  follow  separation  from  the  cord.  His  conclu- 
sions may  be  thus  summed  up  : — 

If  a  spinal  nerve  be  cut  through  at  any  point  between  the  spinal  gan- 
glion and  the  j>eriphery,  the  nerve-fibres  of  the  central  portion  undergo 
atrophy  en  masse,  without  their  individual  character  being  altered ;  but 
the  peripheral  part  of  the  nerve-trunk  undergoes  what  Vulpian  calls 
k*  histopathic  change,"  i.  e.,  a  breaking  up  or  "  splitting"  of  the  medullary 
substance. 

Atrophy  of  muscles  follows  section  of  a  motor  nerve  ;  and,  in  addition 
to  this,  electric  contractility  is  impaired. 

The  absence  of  central  symptoms  of  any  kind,  the  loss  of  both  motion 
and  sensation  in  a  limited  area,  absence  of  reflex  contractions  when  tin- 
sensory  fibres  are  irritated,  and  voluntary  motion  lost,  are  evidences  of 
the  peripheral  nature  of  these  paralyses. 

Treatment — Traumatic  paralysis,  like  the  facial  form,  should  be 
treated  with  an  idea  of  removing  the  cause  should  it  exist,  and  afterwards 
restoring  the  integrity  of  the  nerve  and  muscles,  and  preventing  muscular 
atrophy.  If  the  nerve-trunk  be  severed,  of  course  all  we  can  do  is  to  await 
the  union  of  the  divided  ends.  If  a  tumor  makes  the  destructive  pressure, 
it  should  be  removed  if  possible.  It  is  hardly  necessary  to  allude  to  the 
paralysis  following  dislocations,  for  of  course  the  surgical  proceeding,  which 
is  indicated  at  first,  is  the  reduction  of  the  luxated  bones,  and  this  should 
be  done  as  early  as  possible. 

In  the  management  of  paralysis,  which,  Desplats1  says,  may  be  due  to 
pressure  made  by  osseous  enlargements,  iodide  of  iron  and  other  proper 
remedies,  with  cod-liver  oil,  are  to  be  employed.  If  there  be  neuritis,  it 
should  be  met  with  counter-irritation,  emollient  applications,  or  leeches. 

General  supporting  treatment  may  be  necessary  if  there  be  a  depraved 
condition  of  the  system. 

The  three  valuable  local  forms  of  treatment  are:  1.  Electricity;  2. 
Strychnia,  internally  or  hypodermically  ;  3.  Massage. 

The  first  agent  may  be  used  as  early  as  possible.  If  one  current  will 
not  produce  contractions,  we  may  use  the  other ;  and,  if  complete  sever- 
ance of  the  nerve  has  taken  place,  it  may  be  necessary  to  employ  gal- 
vanism. Faradism  is  especially  valuable  should  there  be  anaesthesia,  and 
may  be  applied  to  the  cutaneous  surface.  The  galvanic  current  may  also 
be  used  at  the  same  time,  so  that  one  electrode  shall  (be  applied  to  the 
spine,  and  the  other  to  the  extremity.  The  individual  muscles  are  to  be 
subjected  to  daily  galvanic  stimulation. 

The  production  of  pain  is  unnecessary,  and  I  may  repeat  the  clinical 
rule  so  tersely  applied  by  H.  C.  Wood  :2  "  Always  select  the  current  which 
produces  the  most  muscular  contractions,  with  the  least  amount  of  pain." 
Pain  and  over-fatigue,  which  follow  the  use  of  a  strong  current,  are  very 

1  DCS  Paralyses  Peripheriques,  Paris,  1876,  p.  45. 

2  Pliila.  Mod.  Times,  Feb.  20,  1875. 


TRAUMATIC    PARALYSIS.  4fi5 

apt  to  thwart  any  probable  success.     The  seance  should  last  not  more  than 
ten  or  fifteen  minutes  every  day. 

An  excellent  method  of  treatment  is  to  place  the  paralyzed  limb  in  a 
vessel  of  warm  salt  water,  and  to  introduce  therein  two  metallic  plates 
connected  with  a  faradic  machine.  If  there  be  neuritis,  electricity  does 
great  harm  and  should  not  be  used. 

I  have  repeatedly  witnessed  the  beneficial  results  which  followed  the 
use  of  hypodermic  injections  of  strychnia  (F.  30).  An  injection  of  ^  of 
a  grain  may  be  thrown  under  the  skin  over  the  paralyzed  muscles.  This 
may  be  repeated  daily ;  and  I  have  sometimes  seen  its  good  effects  when 
electricity  was  without  avail. 

The  use  of  "  massage"  should  be  employed  in  conjunction  with  the  other 
treatment,  and  the  muscles  should  be  separately  kneaded  and  rubbed  for  a 
half  hour  each  day.  This  auxiliary  treatment  is  of  immense  value  when 
there  is  suspected  rheumatic  exudation. 

I  have  often  employed  apparatus  by  which  the  paralyzed  limb  could  be 
subjected  to  warmth,  and  for  this  purpose  have  used  a  heated  drain-pipe 
lined  with  cotton-wool,  such  as  has  been  spoken  of  on  another  page.  Into 
this  the  patient  was  directed  to  place  his  arm  and  allow  it  to  remain  for 
an  hour  or  so  each  day.  The  paralyzed  limb  may  be  wrapped  in  cotton 
and  oil  silk,  or  India-rubber  tissue. 

The  union  of  divided  ends  has  been  resorted  to  by  Tillaux,1  N&aton, 
and  others,  and  with  a  great  deal  of  success.  In  Tillaux's  case  the 
median  nerve  was  united  by  sutures,  and  within  a  day  or  two  the  patient 
was  able  to  move  his  thumb,  and  there  wras  some  return  of  sensation. 

Mitchell2  employs  the  following  method  :  He  carries  a  needle,  threaded 
with  one  or  two  threads,  through  the  loose  tissue  which  is  related  to  the 
nerve-sheath.  The  loops  are  drawn  with  care,  so  that  the  ends  are 
approximated.  Hot  and  cold  douches  and  electricity  are  subsequently 
used. 

In  some  cases  we  may  use  Van  Bibber's  apparatus. 
Van  Bibber  presented  the  following  case  to  the   Maryland   Medico- 
Chirurgical  Society  which  illustrated  the  beneficial  results  of  treatment  of 
this  kind  : — 

"A  youth,  aet.  16,  about  three  years  ago  sustained  a  fracture  of  the  right 
radius,  which  resulted  in  paralysis  and  atrophy  of  the  extensor  group  of 
muscles.  He  first  came  under  my  observation  about  three  months  ago, 
when  I  found  the  following  condition  of  the  arm  :  radius  curved ;  hand 
flexed,  and  the  flexors  acting  inordinately  ;  complete  atrophy  of  the 
extensor  muscles,  it  being  impossible  for  him  to  move  his  hand ;  no 
response  of  the  muscles  to  electricity  ;  and  the  skin  tightly  bound  over  the 
radius.  The  treatment  has  consisted  in  rubbing  and  pinching  the  affected 
muscles,  the  application  of  electricity,  and  the  use  of  the  artificial  muscle, 
which  is  nothing  more  than  an  elastic  tubing  fixed  to  the  back  of  the  arm. 

1  Quoted  by  Weir  Mitchell,  Dis.  and  Inj.  of  Nerves,  p.  238. 

2  Ibid.,  p.  243. 
30 


466  DISEASES    OF    THE    PERIPHERAL    NERVES. 

The  results  of  treatment  have  been  very  satisfactory ;  the  lost 

have  been  restored,  the  skin  has  regained  its  former  tone  and  elasticity, 

and  the  motion  is  fast  returning." 

J  may  in  conclusion  present  a  case  which  was  reported  by  Bernhardt, 
in  which  electricity  was  used. 

"  L.,1  43  years  old ;  dislocated  his  left  humerus  by  falling  on  his  left 
shoulder.  He  had  pain  in  the  shoulder,  and  found  it  impossible  to  use  his 
arm,  and  that  felt  cold.  The  dislocation  was  found  to  be  subcoracoid,  ;unl 
after  eight  days  it  was  reduced.  The  pain  ceased,  but  the  paralysis  con- 
tinued. In  the  palm  of  the  hand  there  was,  after  three  weeks,  consider- 
able scaling  of  the  epidermis.  Pressure  on  the  shoulder  was  not  painful, 
but  a  strong  grasp  of  the  triceps  and  of  the  muscles  of  the  forearm  was 
unpleasant.  Occasionally  there  was  a  sense  of  formication  from  the 
middle  of  the  arm  down  the  extensor  side  of  the  forearm  to  the  end  of  the 
fingers.  The  left  arm  could  be  raised  in  a  straight  line  forward  about 
half  a  foot,  but  could  not  be  carried  backward  nor  across  the  breast.  The 
forearm  could  not  be  bent  on  the  arm  ;  only  the  supinator  longus  was 
rendered  tense.  Extension  was  impossible  ;  supination  was  slight.  The 
hand  could  be  raised  somewhat.  Abduction  and  adduction  of  the  hand, 
flexion  and  extension  of  the  fingers,  were  impossible.  The  prick  of  a 
needle  was  felt  to  the  upper  border  of  the  lower  third  of  the  arm  on  both 
sides  equally.  In  the  lower  third  of  the  left  arm,  in  the  elbow-joint,  and 
the  upper  part  of  the  forearm,  the  skin  is  more  sensitive  on  the  right  than 
the  left.  In  the  rest  of  the  forearm,  in  the  hand  and  fingers,  the  sensa- 
tion is  a  little  less  on  the  left  than  right,  but  nearly  equal.  The  muscles 
of  the  arm  and  forearm,  of  the  hand  and  finger,  as  well  as  the  deltoid, 
showed  only  the  slightest  reaction  to  the  induction  current.  Likewise  the 
use  of  a  very  strong  galvanic  current  either  to  nerve  or  muscle,  by 
opening  or  closing,  failed  to  produce  contraction. 

"  From  the  5th  of  January,  every  other  day,  the  patient  was  treated 
with  a  strong  galvanic  current,  the  anode  and  the  cathode  being  placed  on 
the  paralyzed  muscles.  After  four  weeks  he  could  raise  the  arm  forty 
degrees,  also  some  distance  backward,  so  as  to  touch  the  right  shoulder 
with  the  left  hand.  Also,  he  could  bend  the  forearm  on  the  arm,  and  had 
some  motion  in  the  hand  and  fingers.  After  eight  weeks  more  motion 
was  nearly  restored." 


DIPHTHERITIC  PARALYSIS. 

Diphtheritic  paralysis  may  either  take  place  as  a  feature  of  the  diph- 
theritic attack,  or  it  may  appear  during  convalescence,  or  even  several 
weeks  after  recovery.  The  paralysis  is  generally  bilateral,  and  does  not 
last  any  great  length  of  time  if  the  throat  is  alone  affected,  and  rarely 
exceeds  ten  or  fifteen  days  in  duration.  Should  the  loss  of  power  begin 
at  the  same  time  as  the  acute  disease,  the  progress  of  the  case  is  much 
more  apt  to  be  favorable,  and  the  paralysis  disappears  in  a  shorter  space 
of  time  than  if  it  occurs  at  a  period  subsequent  to  the  disease. 

1  Reported  by  M.  Bernhardt,  Berliner  Klinische  Wochenschrift,  No.  5,  1871. 


DIPHTHERITIC    PARALYSIS.  467 

Lanne  states  that  a  marked  and  sudden  increase  of  temperature  during 
the  diphtheritic  attack  or  convalescence  is  indicative  of  paralysis. 

The  paralysis  may  be  simply  motorial,  or  there  may  be  a  corresponding 
loss  of  sensation  which  is  variable  in  extent. 

The  muscles  of  the  throat  are  usually  involved,  so  that  regurgitation  of 
fluids  takes  place  through  the  nose,  or  there  may  be  certain  phenomena 
which  are  so  well  marked  in  bulbar  paralysis,  in  which  the  lesion  is  one 
of  a  destructive  character.  When  the  limbs  are  paralyzed,  there  may  be, 
according  to  Brenner,  movements  of  a  choreic  character  which  depend 
upon  the  irregularity  of  the  paralysis,  the  antagonism  of  certain  groups  of 
muscles  being  abolished.  The  organs  of  special  sense  are  not  unusually 
involved.  There  may  be  paralysis  of  the  muscles  of  accommodation,1 
neuro-retinitis,  and  sometimes  ptosis.  Deafness  is  not  rare,  and  in  one 
of  my  own  cases  there  had  been  tinnitus  immediately  preceding  -the 
deafness. 

The  following  case  is  of  a  very  interesting  nature,  from  the  fact  that  it 
is  reported  by  the  patient  himself,  who  is  a  medical  man.2 

"  In  October,  1875,  being  twenty-six  years  of  age  and  in  good  health, 
after  two  months'  constant  exposure  to  diphtheria,  I  was  inoculated  from 
a  child  two  years  old,  who,  on  examination,  coughed  portions  of  the  mem- 
brane into  my  face.     Six  days  after  this  exposure  I  was  seized  with  a  chill, 
followed  the  next  day  (October  28th)  by  the  appearance  of  a  diphtheritic 
deposit  on  one  tonsil.     The  deposit  was  limited  to  the  tonsils  and  back 
part  of  the  pharynx,  and  in  nine  days  disappeared.    Exhaustion  and  great 
gastric  irritability  retarded  convalescence.     Four  weeks  passed  before  I 
was  able  to  sit  up.     Two  weeks  after  convalescence  was  declared,  a  sharp, 
lancinating  pain  in  the  left  axilla  was  noticed,  recurring  two  or  three  times 
at  short  intervals.     In  a  few  days,  after  seeing  visitors  or  talking  a  little, 
severe  and  constant  pain  in  the  elbow-joints  occurred,  which  soon  ex- 
tended to  the  muscles  of  the  arm  and  chest.     After  resting,  these  pains 
diminished  or  disappeared,  and  in  a  week  entirely  ceased.    On  attempting 
to  rise,  my  limbs  seemed  surprisingly  weak,  but  at  the  expiration  of  the 
sixth  week  a  short  walk  was  possible.     After  a  brief  period  of  improve- 
ment my  legs  began  to  grow  uncertain  and  weak,  and  by  December  10th 
I  could  take  but  a  few  steps.    At  this  time  a  partial  loss  of  sensation  came 
on,  beginning  in  the  feet  and  gradually  progressing  to  the  trunk,  together 
with  a  feeling  of  coldness  in  the  feet,  which,  however,  were  not  cold  to  the 
touch.     This  numbness  increased  faster  than  the  loss  of  motion.     Soon 
after  its  appearance  in  the  lower  extremities  the  ends  of  the  fingers  lost 
their  sense  of  touch,  the  loss  of  power  also  extending  in  a  week  to  the 
elbows,  and  at  no  time  greatly  affecting  the  arm.     Loss  of  motion  in  the 
fingers  and  forearm  accompanied  it  and  increased  for  some  weeks.     The 
mouth,  tongue,  and  portions  of  the  face  lost  their  sensitiveness  at  the  same 
time  and  to  the  same  degree.     In  a  few  days  my  voice  grew  thick,  and 
was  soon  like  that  caused  by  cleft  palate.     The  soft  palate  and  uvula  hung 
loosely  in  the  mouth,  and  on  attempting  to  swallow  fluids  they  were  regur- 
gitated through  the  nares.     Dimness  of  vision  for  a  short  time  prevented 

1  See  cases  reported  by  Hutchinson,  Lancet,  Jan.  7,  1871. 

2  Dr.  A.  F.  Reed,  Boston  Medical  and  Surgical  Journal,  July  13,  1876. 


468  DISEASES    OF    THE    PERIPHERAL    NERVES. 

reading.  In  three  weeks  my  voice,  then  at  times  unintelligible,  grew  sud- 
denly better,  and  in  four  or  five  days  was  restored.  The  difficulty  in  swal- 
lowing also  soon  disappeared.  The  loss  of  motion  and^  sensation  in  both 
arms  and  legs  increased.  In  walking  I  seemed  to  be  on  velvet ;  there  was 
a  sensation  of  coldness  in  my  feet,  and  at  first  the  circulation  was  retarded. 
The  general  loss  of  power  was  progressive  until  February  1st.  It  was 
then  impossible  for  me  to  stand  alone  even  when  lifted  up,  to  raise  myself 
an  inch  from  the  chair  by  my  arm,  to  bring  my  thumb  and  forefinger 
together,  or  to  exercise  my  strength  in  any  part.  The  toes  hung  lifeless, 
and  no  reflex  action  was  produced  on  tickling  the  sole  of  the  foot.  The 
urine  was  voided  with  difficulty,  and  the  power  of  erection  was  gone. 
The  interosseous  muscles  were  wholly  paralyzed,  though  still  reacting  to 
the  faradic  current.  The  fingers  were  drawn  up  when  the  hand  was  at 
rest,  but  only  by  great  effort  could  be  straightened  out  again.  The  mus- 
cles of  the  arms  were  much  weakened,  but  with  those  of  the  thigh  retained 
more  power  than  the  rest.  They  were  also  the  last  to  lose  and  the  first  to 
gain  motion.  All  these  muscles  were  more  or  less  responsive  to  the  faradic 
current,  the  gastrocnemius  least  of  all.  During  the  weeks  previous  and 
at  this  date  my  appetite  was  excellent,  and  my  food  well  digested.  From 
this  time  an  improvement  as  general  as  the  invasion  was  noticed.  In  one 
week  I  could  lift  my  body  in  the  chair  an  inch  or  two,  and  when  standing 
felt  more  secure.  In  two  weeks  I  could  raise  myself  up  from  the  chair  mainly 
by  my  arms,  and  undressed  without  aid.  At  the  end  of  three  weeks  I 
could  walk  about  the  room  aided  by  a  cane,  and  wrote  legibly.  The  diffi- 
culty in  voiding  the  urine  and  loss  of  power  of  erection  had  by  this  time 
gone.  In  four  weeks  I  walked  out  for  a  short  distance,  and  in  two  weeks 
more  all  paralysis  had  disappeared,  leaving  some  neuralgic  pains  in  the 
knees  and  feet,  which  lasted  but  a  short  time.  On  April  1st  I  walked 
several  miles  without  great  fatigue.  Atmospheric  changes  made  no  change 
in  my  strength.  Insomnia  was  the  greatest  annoyance  suffered  while  con- 
fined to  the  house.  Three  or  four  hours'  sleep  was  all  that  could  be 
obtained.  The  loss  of  sleep  did  not,  however,  leave  me  unrefreshed. 

"  Treatment :  From  January  1 2th  faradism  to  the  muscles  every  day  until 
February  15th,  afterwards  three  times  a  week  for  three  weeks.  Tincture 
of  nux  Tomica  and  tincture  of  phosphoric  ether  were  given  for  ten  days. 
The  stomach  rejecting  these,  one-thirtieth  of  a  grain  of  strychnine  was 
substituted,  which  was  increased  to  one-fifteenth  three  times  daily  for  six 
weeks.  A  pint  of  ale  daily  for  two  months.  Friction  and  kneading  of 
muscles  every  morning  for  one  hour." 

Causes — Morbid  Anatomy  and  Pathology. — Dowse1  quotes 
Balthazar  Foster,  who  has  stated  tiiat  "  he  has  never  known  paralysis  to 
follow  the  non-febrile  form  of  diphtheria."  Dowse  thinks  that  the  vio- 
lence of  diphtheria  has  little  to  do  with  the  development  of  the  paralysis, 
and  says  that  he  has  seen  cases  following  modified  attacks. 

My  own  experience  leads  me  to  disagree  with  him.  I  have  seen  six 
cases  of  diphtheritic  paralysis,  and  these  were  among  the  most  violent 
cases. 

1  See  case  reported  by  Dr.  A.  W.  Foot,  Dublin  Quarterly  Journal,  Sept. 
1872,  ]).  176,  of  "hocomotor  Ataxia  subsequent  to  Diphtheria."  This  was  evi- 
dently the  ataxic  form  of  Brenner. 


DIPHTHERITIC    PARALYSIS.  469 

Labaclie  Lagrave,  Andral,  and  others  have  called  attention  to  the  blood- 
changes  in  this  disease,  viz.,  diminished  fibrine  and  an  increased  number 
of  white  corpuscles.  Saune  has  found  that  the  red  corpuscles  are  de- 
stroyed, and  that  there  is  a  great  increase  in  the  amount  of  debris  with 
albuminous  urine.  The  paralysis  takes  place,  however,  in  a  later  stage, 
but  Dowse  has  shown  that  the  albumen  in  the  urine  reappears  with  the 
paralysis,  and  that  it  again  diminishes  in  quantity  as  recovery  takes  place  ; 
hence  we  may  infer  that  a  connection  exists  between  the  blood  condition 
and  the  paralysis.  I  am  inclined  to  think  that  the  paralysis  of  the  palate  and 
muscles  of  the  pharynx  are  the  result  of  pressure  made  by  the  diphtheritic 
membrane. 

Diagnosis Diphtheritic  paralysis  need  not  be  mistaken  for  any 

other  affection,  though  occasionally,  in  its  ataxic  form,  it  is  confounded 
with  posterior  spinal  sclerosis.  Its  transitory  nature  should  render  such 
an  error  as  this  impossible.  For  the  same  reason  it  should  not  be  con- 
fused with  organic  paralysis. 

Prognosis I  have  never  heard  of  a  fatal  case,  that  is,  a  death  which 

was  a  result  of  paralysis  occurring  during  convalescence  from  diphtheria. 
When  paralysis  takes  place  before  the  violence  of  the  disease  has  been 
spent,  death  may  take  place  from  the  acute  disease.  The  duration  of  the 
paralysis  is  from  eight  or  ten  days  to  many  months. 

Treatment. — Nutritious  food,  massage,  strychnia,  and  iron,  quinine, 
and  stimulants  with  faradization,  are  the  indications.  The  plan  pursued 
in  Dr.  Reed's  case  will  serve  as  a  model. 


470  DISEASES    OF    THE    PERIPHERAL    NERVES. 


CHAPTER   XVIII. 

DISEASES  OF  THE  PERIPHERAL  NERVES  (CONCLUDED). 

LEAD  POISONING. 

Synonyms. — Colica  pictonum  ;  Plumbism. 

The  toxic  effects  of  lead,  whether  taken  internally  or  absorbed  by  the 
skin,  are  extremely  varied  and  interesting.  Disorders  of  motility  and 
sensation  are  produced  which,  though  rarely  alarming,  are  most  distress- 
ing conditions. 

Symptoms Among  the  early  symptoms  of  lead  poisoning  may  be 

mentioned  the  abdominal  pain  which  has  received  the  name  of  colica 
pictonum,  and  which  Romberg1  considers  a  species  of  neuralgia  of  the 
mesenteric  plexuses.  Tanquerel2  has  graphically  sketched  the  appearance 
and  development  of  this  symptom.  At  first  there  is  constipation  which 
lasts  for  some  weeks,  and  sometimes  follows  a  slight  diarrhoea,  while  after 
a  short  time  a  sense  of  epigastric  oppression  is  experienced,  with  nausea 
and  eructations,  and  gnawing  twisting  pains  which  occupy  the  umbilical 
region.  These  pains  are  much  worse  at  night,  and  rarely  shift  their  posi- 
tion. Pressure  relieves  them  to  some  extent,  as  it  does  in  simple  colic. 

During  the  paroxysms  there  is  great  muscular  rigidity,  and  the  ab- 
dominal muscles  seem  to  be  rigid.  The  skin  is  cool,  and  perhaps  bathed 
in  sweat,  and  the  pulse  is  full  and  bounding,  and  quite  hard.  The  con- 
stipation continues,  and  the  feces  that  are  occasionally  voided  are  scyba- 
lous  and  of  a  whitish-gray  color.  The  urine  is  of  high  specific  gravity,  is 
quite  light  in  color,  and  voided  in  considerable  amounts. 

The  complexion  of  the  individual  is  sallow,  and  the  skin  rough;  and,  if 
his  lips  be  separated,  the  peculiar  bluish  line  at  that  part  of  the  gums 
which  is  in  contact  with  the  teeth  will  be  seen.  This  line  is  a  quite  con- 
stant symptom  ;  it  is  perhaps  one  of  the  most  valuable  diagnostic  marks. 
The  remaining  part  of  the  gums  is  quite  spongy  and  dark. 

There  may  be  in  conjunction  with  lead  colic  a  very  well-marked  cuta- 
neous anaesthesia  or  hypenesthesia,  but  the  latter  is  more  common.  The 
skin  is  exquisitely  sensitive  in  parts,  such  as  the  scalp,  the  groin,  the  bend 
of  the  elbow,  and  other  like  regions.  Pressure  seems  to  relieve  this  ten- 
derness, but  light  irritation  aggravates  it  markedly. 

A  form  of  tremor  which  is  apt  to  be  confused  with  those  of  a  sclerotic 
nature  has  been  found  as  a  rare  symptom.  Brockman  observed  it  among 

1  Op.  cit..  vol.  ii.  p    132. 

2  Traitls  des  Maladies  de  Plomb.  on  Saturnines,  1839. 


LEAD    POISONING.  4Y1 

workers  in  the  lead  mines  of  the  Hartz  Mountains.  It  may  be  local  or 
general,  and  in  the  first  form  the  hands  are  affected.  The  lips  may  be 
agitated,  and  the  levator  anguli  oris  is  often  involved,  so  that  the  corner  of 
the  mouth  is  drawn  up.  In  the  other  form  the  head,  trunk,  and  arms  are 
all  in  a  state  of  tremor,  the  head  being  bowed  on  the  chest,  and  the  legs 
unsteady.  In  this  latter  form  there  is  usually  a  profound  toxic  condition. 

By  far  the  most  important  symptom,  and  one  which  may  or  may  not  be 
preceded  by  lead  colic,  is  the  form  of  local  paralysis  known  as  "  lead  palsy" 
or  "  lead  paresis."  The  onset  of  the  malady  is  usually  gradual,  the  patient 
being  unable  at  first  to  extend  the  fingers.  There  is  nearly  always  some 
numbness  of  the  hand,  and  rarely  tremor.  It  is  not  often  that  the  para- 
lysis becomes  general,  but  the  extensors  of  the  forearms  are,  as  a  rule, 
involved.  In  this  condition  the  hands  hang  helplessly,  and  an  appearance 
results  which  has  been  called  "  drop  wrist."  There  is  generally  some 
paralysis  of  the  flexors,  but  this  is  almost  inappreciable.  Other  muscles, 
notably  those  of  the  shoulder,  are  affected  if  the  lead  saturation  be  pro- 
found, and,  as  a  consequence,  the  patient  may  be  unable  to  raise  his  arm. 
I  have  never  seen  a  case  in  which  the  lower  extremities  were  involved. 

Electric  sensibility  and  contractility  are  much  reduced,  and  there  is 
marked  anaesthesia  in  most  of  the  cases.  Faradism  rarely  provokes  mus- 
cular contractions,  and  in  old  cases  even  the  galvanic  current  fails  to  call 
forth  the  slightest  response. 

Atrophy  is  a  result  of  the  paralysis,  and  the  interosseous  spaces  of  the 
forearm  are  sometimes  very  plainly  marked,  the  loss  of  substance  being 
quite  decided. 

The  colic  generally  subsides  with  the  appearance  of  the  paralysis,  and 
according  to  Romberg1  the  two  conditions  rarely  coexist.  In  the  cases 
recorded  by  various  observers  the  muscles  of  both  extremities  of  one  kind 
were  affected  in  the  great  majority  of  instances,  and  from  my  own  expe- 
rience I  consider  unilateral  lead  paralysis  to  be  an  anomalous  condition. 

Occasionally  a  cerebral  condition  results  from  lead  poisoning,  and  gene- 
rally follows  the  colic.  This  is  characterized  by  vertigo  and  headache, 
general  malaise,  and  tremor  of  the  hands  which  is  aggravated  by  volun- 
tary action.  A  more  serious  state  is  sometimes  produced,  however,  which 
is  symptomatized  by  delirium,  convulsions,  and  stupor. 

The  duration  of  lead  paralysis,  or  the  other  condition  I  have  noticed,  is 
of  course  governed  by  the  existence  of  the  cause  and  the  exposure  of  the 
patient.  Most  of  the  toxic  lead  states  disappear,  however,  in  a  very  short 
time,  provided  the  patient  protects  himself  by  leaving  his  injurious  occu- 
pation, and  the  proper  remedies  be  administered. 

The  following  may  be  cited  as  a  well-marked  case  of  lead  poisoning : — 

Jas.  McK.,  set.  55,  N.  Y.  City,  painter.  Has  followed  his  trade  35  years, 
engaged  mostly  on  "inside  work,"  "flatting."  Never  had  any  trouble 
till  two  years  ago,  when  he  noticed  pains  in  his  limbs,  back,  and  subocci- 

1  Op.  cit.,  vol.  ii.  p.  136. 


472  DISEASES    OF    THE    PERIPHERAL    NERVES. 

pitnl  region  ;  not  much  colic,  but  some  nausea  ;  loss  of  appetite  ;  not  con- 
stipated. While  actually  engaged  in  work  he  became  dizzy,  and  "  a  blur 
came  across  his  eyes."  Last  acute  attack  was  obliged  to  leave  work  sud- 
denly on  account  of  severe  backache.  He  then  noticed  a  loss  of  power  in 
right  hand.  He  consulted  me  in  July,  1877,  presenting  well-marked 
"  wrist  drop,"  so  that  he  was  unable  to  extend  his  hand.  He  complained 
of  formication  of  soles  of  feet,  insomnia,  and  pains  in  shoulders,  knee- 
joints,  and  about  heart.  Well-marked  blue  line  and  very  dirty  gums. 
The  necks  of  the  teeth  are  carious  and  black,  and  he  has  lost  several  of 
them  during  the  past  few  years. 

Loss  of  sensation  of  cutaneous  surface. 

Jfand.* — Atrophy  of  adductor  of  thumb,  so  that  quite  a  hollow  exists. 

Forearm Complete  loss  of  electro-muscular  contractility  in  common 

extensor  of  right  forearm ;  slight  power  under  electrical  stimulus  of  ex- 
tensor of  thumb  and  little  finger.  Flexors  slightly  impaired,  but  con- 
tractility scarcely  lost. 

Arm Muscles  all  contract  well.  Patient  cannot  take  off  his  coat  or 

underclothing,  or  cannot  button  his  clothes. 

Treatment — PUectricity  and  potass,  iodid.  with  strychnine. 

Causes. — The  majority  of  cases  of  lead  poisoning  arise  from  the  inspi- 
ration of  finely  divided  particles  of  lead,  and  not  from  the  manipulation  of 
pieces  of  the  metal;  consequently,  painters,  smelters,  white-lead  makers, 
and  miners  are  more  often  victims  than  any  other  classes  of  individuals. 
There  seems  to  be  an  idea  that  printers  are  especially  subject  to  lead  dis- 
eases ;  and  at  the  request  of  the  Board  of  Health  of  the  city  of  New  York 
I  made  an  extensive  examination  of  the  printing-offices  for  the  purpose 
of  testing  the  question.  I  interviewed  nearly  1500  men,  women,  and 
children,  and  found  not  a  single  case  of  paralysis.  Among  the  grinders 
of  type  (those  who  smooth  the  sides  and  ends  of  the  type  against  large 
rough  stones),  I  found  that  the  persistent  use  of  the  muscles  of  the  thumb 
and  forefinger,  in  one  case,  resulted  in  a  condition  resembling  progressive 
muscular  atrophy.  In  the  lead  pipe  and  shot  manufactories  my  experience 
was  the  same. 

The  painters,  however,  seem  to  be  most  frequently  poisoned.  An  ope- 
ration known  as  "  flatting,"  in  which  the  painter  closes  all  the  doors 
and  windows  of  a  room,  and  applies  thin  paint,  is  attended  with  great 
danger.  The  turpentine  evaporates  rapidly,  and  carries  with  it  minute 
particles  of  lead  which  the  workman  must  inhale. 

Dr.  Richardson,2  in  a  thesis  which  embodies  a  large  amount  of  valuable 
research,  thus  describes  the  manner  of  preparing  white  lead,  and  the  dan- 
ger which  attends  its  manufacture. 

"The  metal  first  comes  in  contact  with  the  skin  of  the  men  in  being 
carried  by  hand  from  the  cars  to  the  melting-room.  Here  many  tons  are 
melted  at  once  and  cast  into  thin,  circular,  perforated  plates  called  buckles, 
of  such  shape  as  to  expose  as  much  surface  as  possible  for  the  weight. 

1  Can  only  force  dynamometer  index  to  4  with  right  hand  ;  left,  1 5. 

2  Graduation  Thesis,  Harvard  Medical  School — Boston  Med.  and  Surg.  Journ., 
Oct.  4,  1877. 


LEAD    POISONING.  473 

The  temperature  is  very  high.  Bathed  in  perspiration  the  men  stand  for 
hours  inhaling  the  minute  particles  of  the  oxide  of  lead  which  escape 
from  the  cooling  buckles  and  fill  the  air.  Their  thirst  in  this  part  of  the 
process  is  insatiable,  and  enormous  quantities  of  ice-water  are  swallowed, 
whereby  the  dust,  which  adheres  to  the  tongue  and  lips,  is  washed  directly 
into  the  stomach. 

Having  been  carried  to  a  neighboring  shed,  the  buckles  are  placed  over 
pyroligneous  acid  in  earthen  pots  of  about  four  quarts  capacity.  Many 
thousand  of  these  pots  are  packed  together  in  the  refuse  of  stables  or  the 
exhausted  bark  from  tanneries,  and  are  exposed  to  the  moderate  heat 
which  is  spontaneously  generated  about  them.  The  wood  vinegar  is  vola- 
tilized and  rises  through  the  buckles,  changing  by  some  obscure  chemical 
reaction  the  blue  metallic  lead  into  the  white  carbonate.  After  an  ex- 
posure of  this  sort,  lasting  from  six  weeks  to  three  months,  the  pots  are 
unpacked  and  the  whitened  lead  removed.  Here  for  hours  men  breathe 
the  vapors  rising  from  the  heated  bark,  loaded  with  poisonous  particles  of 
the  now  dusty  metal.  In  English  mills  this  part  of  the  process  is  done 
by  women,  with  most  disastrous  effects  upon  the  health.  To  separate  the 
blue  from  the  white  lead  the  buckles  are  placed  in  a  revolving  cylinder  of 
wire-cloth,  through  which  the  carbonate,  more  or  less  pulverized,  falls. . 
The  blue  portion  remains  in  the  cylinder  and  is  melted  again.  To  be  in 
this  room  without  protection  is  suicidal,  for  the  air  is  filled  with  visible 
clouds  of  dust.  The  utmost  care  must  be  taken.  The  mouth  and  nostrils 
are  covered  by  a  moist  sponge  to  catch  the  floating  particles.  The  skin 
and  clothes  quickly  become  white  with  lead.  The  semi-powdered  metal, 
having  been  shovelled  into  barrels  and  rolled  into  another  division  of  the 
works,  is  mixed  with  water  and  finely  ground.  When  it  fills  the  water 
as  a  milky  precipitate,  the  whole  is  drawn  off  and  dried  on  long  tables  at 
a  temperature  of  140°  F.  Formerly  the  grinding  was  done  without 
water,  and  the  lead  sickness  was  much  more  common  than  now.  The 
drying-room  is  the  most  poisonous  one  in  modern  mills.  It  combines  the 
effects  of  the  dust  which  fills  the  air  with  those  of  a  heated  atmosphere. 
Here,  as  in  the  melting-room,  the  skin  is  kept  in  the  best  state  for  absorp- 
tion. A  terrible  thirst  makes  the  men  swallow  large  quantities  of  cold 
water  with  the  lead  which  accumulates  on  their  lips  and  tongues,  while  at 
every  breath  fine  dust  is  drawn  into  the  lungs. 

The  general  appearance  of  the  men  is  not  good.  The  faces  are  sallow 
and  more  or  less  worn.  The  sclerotic  coat  is  yellowish.  Their  motions 
are  far  from  energetic,  and  in  some  cases  eccentric  and  unsteady.  One 
would  say  immediately,  I  think,  that  the  general  appearance  is  much 
below  that  of  the  average  workman. 

1.  The  first  man  examined  has  worked  in  all  parts  of  the  mill  for  thir- 
teen years.     His  only  trouble  is  rheumatism.     The  gums  show  a  distinct 
blue  line  along  the  border. 

2.  After  seven  years  in  the  corroding  rooms  has  no  symptoms  excepting 
the  blue  line. 

3.  After  grinding  lead  with  oil  has  only  the  blue  line. 


474  DISEASES    OF    THE    PERIPHERAL    NERVES. 

4.  After  working  in  all  parts  of  the  mill  for  six  months  has  had  violent 
colic  and  great  constipation.  Blue  line  marked. 

,5.  Reports  only  blue  line  after  four  years'  work. 

6.  The  machinist,  after  repairing  in  the  drying-room  a  few  hours  a  day 
for  ten  days,  was  affected  with  colic  and  constipation.  Has  great  habit- 
ual constipation.  Blue  line  very  marked. 

I.  After  seven  years  only  blue  line. 

8.  After  twelve  years  has  only  blue  line  and  fungous  bleeding  gums, 
with  occasional  colic  and  obstinate  constipation. 

9.  After  six  years  in  corroding-room  has  only  blue  line. 

10.  Has  worked  in  all  parts  of  the  mill  for  fifteen  years  without  show- 
ing a  trace  of  blue  line  or  any  other  symptoms  whatever.     Very  neat. 

I 1 .  After  three  years  only  blue  line. 

1 2.  After  four  years,  nothing. 

13.  Blue  line,  rheumatic  pains,  and  fainting  fits.     This  was  a  remark- 
ably neat  man. 

14.  After  four  years  no  trace  of  poisoning. 

lo.  After  four  years  entirely  used  up.     Had  to  leave  all  work. 

16.  After  one  year's  work  completely  crippled,  having  paralysis  of  the 
extensors,  aphonia,  and  general  debility. 

17.  The  carpenter,  after  repairing  ten  days  in  the  drying-room,  had 
severe  colic,  obstinate  constipation,  and  persistent  blue  line. 

18-75.  Of  the  rest  of  the  seventy-five  men  whom  I  examined  all  Imd  a 
distinct  blue  line  about  the  gums,  and,  with  one  or  two  exceptions,  habit- 
ual constipation.  There  was  nothing  further  than  this  to  suggest  the 
presence  of  lead. 

In  addition  to  the  above  cases,  three  of  the  former  employe's  had  suf- 
fered with  difficulty  in  speaking,  three  with  amaurosis,  several  with  cere- 
bral troubles,  and  many  with  paralysis.  The  superintendent  has  observed 
that  the  most  frequent  complaint  has  been  of  swollen  joints  and  aching 
bones.  In  the  numerous  cases  of  paralysis  which  he  has  seen  during 
many  years'  service  at  these  works,  he  has  noticed  that  the  wrists  have 
become  much  swollen  before  paralysis  of  the  extensors.  A  curious  tradi- 
tion exists  among  them  that  they  cannot  drink  alcoholic  liquors  and  keep 
up  with  their  work,  like  laboring  men  in  other  manufactories.  Several 
cases  were  told  me  of  men  who  quickly  succumbed  to  the  influence  of  the 
lead  after  beginning  the  use  of  strong  stimulants." 

Load  is  often  taken  into  the  stomach  without  the  knowledge  of  the  in- 
dividual, and  lead  pipes  are  a  prolific  source  of  the  contamination  of 
water.  I  have  seen  three  cases  in  the  same  family  caused  by  tea  which 
had  been  made  from  a  specimen  containing  particles  of  sheet  lead  which 
had  lined  the  box.  The  last  two  or  three  pounds  were  impregnated  with 
these  impurities,  which  had  settled  to  the  bottom  of  the  chest.  It  was 
the  custom  to  make  tea  and  from  time  to  time  to  add  fresh  leaves  and  pour 
on  hot  water,  so  that  there  was  constantly  a  quantity  of  lead  subjected  to 
the  action  of  the  fluid.  Upon  analysis,  quite  an  amount  of  lead  was 
found. 


LEAD    POISONING.  475 

Cases  arising  from  the  use  of  cosmetics  and  hair-dyes  are  too  common 
to  need  anything  more  than  bare  mention. 

Morbid  Anatomy  and  Pathology — Andral  and  Tanquerel1  were 
unable  to  discover  any  pathognomonic  condition  of  the  intestines  in  lead 
colic  ;  but  the  latter  authority  found  lead  deposits  in  the  intestines,  mus- 
cles, and  nervous  substances.  In  a  case  of  lead  paralysis  reported  by 
Gombault,2  there  was  found  to  be  no  change  in  the  cord,  and  the  only 
morbid  appearances  anywhere  else  were  in  the  nerves,  the  medullary  sub- 
stance having  undergone  a  granular  alteration.  No  other  appearances 
which  might  clear  up  the  pathology  of  the  affection  have  been  seen. 

Remak3  is  of  the  opinion  that  lead  palsy  is  a  central  disease,  and  he 
presents  several  cases  to  show  its  likeness  to  infantile  paralysis.  The 
same  electrical  reaction  of  the  muscles  in  these  two  affections,  and  the 
fact  that  groups  of  muscles  are  affected  which  act  together,  not  necessarily 
being  those  supplied  by  the  same  nerve,  lead  him  to  think  that  the  paraly- 
sis is  of  central  origin.  The  blue  line  of  the  gums,  which  indicate  plum- 
bic saturation,  was  first  described  by  Burton  in  1840.  By  Tanquerel  it 
is  supposed  to  be  produced  by  the  decomposition  of  food  about  the  teeth, 
the  sulphuretted  hydrogen  uniting  with  the  lead.  It  occurs  in  people  who 
brush  their  teeth  as  well,  however,  as  in  those  of  careless  and  untidy 
habits.  Dr.  Richardson4  tried  the  following  experiment: — 

"  A  strong,  healthy  cat  was  fed  for  a  week  upon  milk,  to  which  had 
been  added  a  small  portion  of  a  solution  of  plumbic  acetate.  At  the  end 
of  a  week  the  animal  was  killed,  after  having  shown  symptoms  of  severe 
constitutional  disturbance.  The  lower  jaw  was  excised,  and  the  gums 
found  perfectly  clean.  The  upper  jaw  was  also  clean.  The  lower  jaw 
was  placed  in  water,  through  which  a  stream  of  sulphuretted  hydrogen 
was  passed  for  several  hours.  At  the  end  of  that  time  a  perfectly  distinct 
and  unmistakable  blue  line  was  found  throughout  the  juncture  of  the  gum 
with  the  teeth.  The  stomach  and  intestines  of  the  animal  showed  nothing 
remarkable.  The  presence  of  the  blue  line  seems,  therefore,  to  depend 
on  a  certain  amount  of  putrefaction  about  the  teeth." 

The  elimination  of  lead  is  usually  rapid  when  the  proper  remedies  are 
administered  to  convert  it  into  a  form  for  excretion.  If  nature  is  left 
to  herself,  the  process  is  more  slow.  Potain  considers  that  it  is  eliminated 
only  very  slowly  by  the  sweat-glands,  and  not  by  the  kidneys  or  salivary 
glands,  but  I  am  disposed  to  consider  that  elimination  does  take  place  by 
the  kidneys. 

Diagnosis In  nearly  all  cases  of  lead  poisoning,  it  is  usually  possi- 
ble to  detect  the  cachexia,  which  is  so  well  expressed  by  the  different 
signs  I  have  enumerated.  If  our  suspicions  are  not  verified  by  appear- 
ances in  an  acute  case,  we  may  test  the  patient's  urine.  A  few  drops  of 

1  Tanquerel,  p.  326.  2  Archiv.  G6n6rales,  1873. 

3  Archiv  fur  Psychiatric  uud  Nervenkrankheiten,  vi.  p.  1. 

4  Op.  cit. 


476  DISEASES    OF    THE    PERIPHERAL    NERVES. 

a  solution  of  sulphide  of  potassium  will  usually  precipitate  any  lead  that 
may  be  present  in  the  form  of  a  black  sulphide. 

The  paralysis  may  be  sometimes  confounded  with  other  forms,  but  when 
it  is  remembered  that  the  extensors  are  prominently  affected,  and  that 
there  are  lead  symptoms  at  some  time  or  other,  it  is  not  possible  to  be  mis- 
taken. 

Dr.  Wharton  Sinkler,1  in  an  admirable  paper,  calls  attention  to  the 
resemblance  between  "wrist  drop"  due  to  lead  poisoning,  and  paralysis  of 
the  extensors  from  injury  of  the  musculo-spiral  nerve.  He  has  found 
paralysis  of  the  flexors  of  the  forearm  after  injury  of  the  nerve,  and  he  is 
inclined  to  think  that  in  the  beginning  there  is  never  paralysis  of  the 
flexors  in  lead  palsy. 

Prognosis. — With  the  disappearance  of  the  cause,  we  may  expect  in 
most  cases  a  rapid  subsidence  of  symptoms.  It  is  true  the  paralysis  often 
lasts  for  some  time,  but  even  this  ultimately  disappears.  Deaths  by  lead 
poisoning  are  rare,  and  I  suppose  when  they  occur  are  due  to  an  affection 
of  the  brain,  to  which  I  have  alluded.  The  mortality  from  lead  poisoning 
in  New  York  City  from  1852  to  1873  was  288.  48  died  in  1852  ;  and, 
strange  to  say,  but  four  in  1872.* 

Treatment — If  we  have  correctly  diagnosed  the  condition,  our  ob- 
jects must  be  :  1.  To  relieve  pain  ;  2.  To  favor  elimination  of  the  lead  ; 
3.  To  guard  our  patient  against  being  continually  affected  ;  4.  To  restore 
the  paralyzed  limbs. 

1.  No  better  remedy  is  possessed  than  iodide  of  potassium,  which  forms 
an  iodide  of  lead  which  is  an  innocuous  salt.  This  drug  must  be  given  in 
moderate  doses,3  and  its  elimination  hastened  by  mild  purgatives.  It  will 
be  found  that,  if  the  patient  is  obliged  to  continue  at  his  work,  small  doses 
taken  daily,  or  acidulated  drinks,  will,  in  some  measure,  prevent  the  ab- 
sorption of  lead.  If  there  be  colic,  the  hypodermic  use  of  morphine  will 
give  great  relief. 

It  has  been  found  that  those  workmen  who  drink  a  great  deal  of  milk 
seem  to  escape  the  danger  of  lead-poisoning.  In  France  the  workmen  in 
the  lead-works  are  obliged  to  drink  milk,  and  it  is  found  to  be  an  excellent 
prophylactic.  Kichardson's  case  (loc.  cit.)  did  not  suffer  so  long  as  he  kept 
his  cows ;  but  when  he  parted  with  these  animals,  and  stopped  drinking 
milk,  the  most  decided  symptoms  of  plumbism  manifested  themselves. 

As  to  the  employment  of  electricity,  it  is  well  to  use  the  faradic  current 
if  possible ;  but  in  some  cases  this  produces  no  contractions.  In  such 
an  event  we  may  begin  with  the  slowly  intermitted  galvanic  current ;  and, 
after  a  while,  it  will  be  found,  as  in  some  other  paralyses,  that  the  faradic 
will  cause  muscular  response,  particularly  if  the  arm  be  so  supported  that 
the  muscles  shall  be  relaxed.  Dr.  H.  C.  Wood,*  of  Philadelphia,  has 

'•   Am.  Psych.  Journal,  Nov.  1875,  p.  31. 

3  Report  of  the  Board  of  Health,  1872. 

8  Very  large  doses  seem  to  increase  the  symptoms. 

4  Phila.  Med.  Times,  Feb.  20,  1875. 


LEAD    POISONING.  477 

noticed  the  fact  that  voluntary  power  may  return  to  a  great  degree  without 
a  corresponding  return  of  electric  contractility. 

I  have  before  alluded  to  an  instrument  devised  by  Dr.  J.  Van  Bibber,1 
and  it  is  well  to  apply  this  so  that  the  muscles  may  be  entirely  supported. 

In  conclusion,  I  may  present  the  records  of  a  representative  case  of 
lead  palsy.  The  patient  was  under  the  care  of  Dr.  Cross,  through  whose 
kindness  I  had  the  opportunity  of  seeing  him  : — 

M.  C.,2  aged  32  years,  single,  born  in  Ireland,  a  painter  by  occupation. 
He  has  been  moderately  temperate  in  his  habits,  and  has  always  enjoyed 
good  health  until  1863,  when  he  was  suddenly  seized  with  a  severe  attack 
of  colic,  which  was  preceded  by  great  constipation  of  the  bowels  and  loss 
of  appetite.  There  soon  succeeded  nausea  and  vomiting  of  bile,  accom- 
panied by  an  acute  lancinating  pain  in  the  epigastric  region,  which  was  so 
severe  that  the  patient  was  obliged  to  lie  flat  on  the  floor  and  press  his 
abdomen  strongly  against  that  surface,  in  order  to  obtain  temporary  relief. 


1  ' '  After  many  attempts  to  secure  this  advantage  by  means  of  strips  of  plaster, 
it  was  determined  to  try  the  India-rubber  muscle  as  used  by  Dr.  Lewis  A.  Savre 
in  orthopedic  surgery.     The  great  difficulty  in  the  use  of  such  an  appliance  was 
to  effect  its  application  without  causing  injurious  pressure  upon  the  circulation  of 
the  arm  and  hand.    I  am  not  aware  that  these  elastic  tubes  have  been  used  before 
to  correct  this  deformity,  or  attached  by  a  method  so  simple  and  so  free  from 
pressure  as  that  which  I  shall  now  describe.      Two  bands  of  inelastic  webbing, 
pierced  by  eyelets  at  certain  points,  and  each  having  a  convenient  buckle,  serve 
as  points  of  attachment.     The  one  for  the  hand,  about  three-quarters  of  an  inch 
wide,  so  made,  that  the  free  end  placed  upon  the  palm  pointing  toward  the  the- 
nar  eminence,  and  the  eyelet-hole  resting  on  the  ball  of  little  finger,  the  band 
folded  once  around  that  finger  and  passed  over  dorsum  of  the  hand,  the  buckle 
would  come  in  a  convenient  place  upon  the  palmar  surface.      The  band  for  the 
arm  about  one  inch  in  width,  so  arranged  that  the  eyelet  being  placed  upon  a 
line  a  little  above  the  external  condyle,  the  buckle  would  rest  upon  the  internal 
surface  of  the  arm. 

As  seen  in  the  illustration,  two  transverse  strips  of  plaster  are  adjusted  to  the 
arm  so  as  to  form  an  angle  just  below  the  eyelet,  and  thus  relieve  the  band,  which 
should  be  buckled  loosely,  from  all  injurious  traction.  The  fold  around  the  little 
finger,  and  the  muscle  resting  upon  the  webbing  on  the  dorsum  of  the  hand, 
enable  us  to  buckle  the  band  loose  enough  to  insure  perfect  abduction  of  all  the 
fingers.  Finally,  a  piece  of  India-rubber  tubing  of  correct  length  and  medium 
elasticity,  with  one  of  Dr.  Sayre's  metallic  hooks  attached  at  each  end,  consti- 
tutes the  entire  apparatus. 

Looking  upon  this  artificial  muscle  as  performing  to  some  extent  the  duty  of 
those  paralyzed,  I  can  probably  best  describe  its  application  by  saying,  in  ana- 
tomical language,  that  it  arises  from  a  point  a  little  above  the  external  condyle. 
and  passing  downward  on  the  extensor  surface  of  forearm,  under  the  cuff,  which 
we  might  call  the  annular  ligament,  forward  over  dorsal  aspect  of  the  hand,  pass- 
ing between  the  index  and  second  fingers,  which  serve  as  a  trochlca  or  pulley, 
then  transversely  across  the  palmar  surface  of  the  hand,  and  is  inserted  at  a  point 
about  the  articulation  of  the  fifth  metacarpal  bone  with  its  first  phalange." — -V. 
Y.  Med.  Journ.,  May,  1874. 

2  Reported  in  the  Psychological  Journal,  Jan.  1871,  by  Dr.  Cross. 


478  DISEASES    OF    THE    PERIPHERAL    NERVES. 

These  symptoms  continued  off  and  on  for  a  period  of  about  two  weeks, 
gradually  diminishing  in  severity,  however,  especially  after  an  evacuation 
from  the  rectum,  which  was  only  obtained  with  the  greatest  difficulty. 
His  right  leg  at  this  time  became  oedematous.  In  the  course  of  two  months 
lie  resumed  his  usual  avocation,  that  of  a  painter,  but  was  not  aware  at 
this  time  that  his  sickness  had  been  caused  by  the  action  of  lead.  During 
the  year  18G7  his  bowels  again  became  very  costive;  and  his  stools,  which 
consisted  of  only  a  few  lumps  of  dry,  hardened  feces,  were  attended  with 
much  straining. 

Soon  there  followed  a  second  attack  much  more  severe  than  the  first, 
which  was  characterized  by  nearly  similar  symptoms,  only  there  was 
superadded  great  tenderness  over  the  kidneys,  which  were  so  sensitive 
that  the  least  pressure  caused  him  the  most  intense  agony.  The  urine 
was  very  scanty  and  high-colored,  and  there  was  a  well-marked  blue 
discoloration  of  the  gums.  In  a  few  months,  having  somewhat  recovered, 
he  went  to  work  again  at  his  former  occupation,  which  he  pursued  unin- 
terruptedly until  the  25th  of  December,  1809,  when,  after  having  passed 
a  very  uncomfortable  day,  his  former  symptoms  returned  with  increased 
violence,  while  the  paroxysms  of  the  colic  came  on  at  much  shorter  inter- 
vals than  they  had  done  in  the  preceding  seizures ;  in  fact,  instead  of 
intermissions  as  formerly,  there  were  only  remissions  of  the  intestinal 
spasm.  For  the  first  time  he  had  pains  in  the  feet  and  the  inside  of  the 
thighs.  The  urine  was  more  scanty  and  higher  colored,  and  the  bowels 
more  constipated  than  before. 

In  three  weeks  he  again  began  to  work,  and  had  no  more  trouble, 
except  constipation  of  the  bowels  and  weakness  in  both  his  upper  and 
lower  extremities,  until  July,  1870,  when  he  lost  his  appetite,  and  felt 
very  weary  and  exhausted  after  any  small  amount  of  exertion.  He  was 
very  restless  and  could  not  sleep  at  night,  and  this  inability  to  sleep  was 
a  sequela  of  all  the  other  seizures.  Now  came  great  tremor  of  the  right 
hand  and  arm,  which  was  soon  followed  by  tremor  in  the  left. 

In  August,  1870,  he  had  his  fourth  and  last  attack,  which  was  the  most 
severe  of  all,  and  lasted  about  two  weeks.  This  time  he  vomited  blood, 
had  acute  pains  in  the  soles  of  his  feet,  and  cramps  in  the  right  hand.  On 
recovering  from  the  effects  of  the  colic  he  found  that  he  was  unable  to  use 
his  arm  or  hand  at  all,  and  that  he  had  lost  power  in  his  legs  also. 

Soon  after  this  he  was  admitted  to  the  Charity  Hospital,  where  he 
remained  for  a  fortnight,  and  during  his  residence  in  that  institution  he 
became  delirious,  and  continued  so  for  about  eighteen  hours.  He  came 
to  the  out-door  department  of  the  New  York  State  Hospital  for  Diseases 
of  the  Nervous  System,  September  12,  1870,  when  his  condition  was  as 
follows  :  There  was  the  characteristic  drooping  of  both  wrists,  which  was 
very  extreme  in  degree.  The  paralysis  of  the  supinator  and  extensor 
muscles  of  both  upper  extremities  was  exceedingly  well  marked ;  the 
flexors  were  also  involved,  only  to  a  much  more  limited  extent.  The 
paralysis  was  more  considerable  in  the  right  forearm  and  hand  than  in  the 
left.  There  was  much  atrophy  of  all  the  muscles  of  these  parts,  and  this 
was  very  conspicuous  in  the  abductors  and  adductors  of  the  thumbs.  The 
patient  was  so  very  weak  in  his  lower  extremities  that  he  was  unable  to 
arise  from  the  sitting  posture  without  assistance,  and  as  he  walked  he  tot- 
tered at  every  step.  Yet  he  did  not  drag  the  toe  of  either  foot,  nor  swing 
his  legs,  as  do  those  suffering  from  hemiplegia.  The  blue  line  was  very 
plainly  seen  around  the  edge  of  the  gums  of  the  upper  and  lower  jaws. 


FUNCTIONAL    SPASM.  4T9 

On  testing  the  amount  of  muscular  power  in  the  right  hand  by  means  of 
the  dynamometer,  he  was  able  to  turn  the  indicator  only  10  degrees, 
while  with  the  left  he  could  accomplish  somewhat  more.  The  tactile 
sensibility  and  the  sensibility  to  the  electric  current  and  to  pain  were  very 
greatly  diminished.  The  temperature  was  also  diminished;  muscular 
contractility  was  so  much  impaired  that  a  powerful  induced  current  had 
not  the  slightest  effect  in  causing  contractions,  and,  even  when  the 
primary  galvanic  current  (sixty  cells  and  very  strong)  was  used,  the 
muscles  responded  very  feebly,  if  we  except,  perhaps,  the  flexors,  so 
almost  completely  had  their  irritability  been  destroyed.  The  bowels  were 
regular,  the  urine  was  normal,  and,  although  no  chemical  analysis  for 
lead  was  made,  undoubtedly  it  would  have  been  found.  "  The  appear- 
ance of  the  patient  was  anaemic,  cachectic,  and  depressed ;  the  breath 
was  very  offensive  ;  the  retinae  were  ansemic  ;  the  lungs  were  healthy,  and 
so  was  the  heart,  excepting  an  inorganic  murmur  at  its  base." 

The  treatment  in  this  case  has  consisted  of  the  internal  administration 
of  the  iodide  of  potassium,  commencing  with  ten-grain  doses  three  times  a 
day,  and  the  daily  application  of  the  primary  galvanic  current  to  the 
paralyzed  muscles,  with  a  hypodermic  injection  of  the  thirty-second  of  a 
grain  of  the  sulphate  of  strychnia  every  day. 

September  17.  The  iodide  was  increased  to  fifteen  grains  three  times 
a  day. 

'2±th.  Slight  fibrillary  contractions  in  the  right,  arm  were  produced 
to-day  for  the  first  time  by  means  of  the  faradic  current. 

October  1.  The  iodide  of  potassium  was  increased  to  twenty  grains 
three  times  a  day. 

5th.  The  induced  current  had  just  commenced  to  cause  slight  contrac- 
tions in  the  left  forearm. 

November  15.  Faradization  of  the  left  forearm  produced  good  con- 
tractions in  the  extensor  carpi  radialis  and  ulnaris  muscles.  The  blue 
line  having  disappeared,  the  iodide  of  potassium  was  discontinued,  and  a 
tonic  substituted. 

23d.  The  muscles  of  both  arms  respond  feebly  to  the  induced  current, 
yet  by  means  of  it  the  hands  can  now  be  extended  nearly  on  a  level  with 
the  forearms.  The  right  has  improved  the  most.  Sensibility  to  touch 
and  to  electricity  has  much  improved.  His  bowels  are  regular,  he  sleeps 
well,  and  his  appetite  is  good.  The  power  in  both  hands  is  much  in- 
creased, and  he  is  able  to  work  every  day. 

January  1,  1871.  The  patient  has  almost  entirely  recovered. 


FUNCTIONAL  SPASM. 

Under  this  head  I  propose  to  include  the  various  forms  of  hyperkinesis 
which  depend  upon  irritability  of  the  nervous  centres,  and  which  have  been 
specially  considered,  as  Tetany,  spasm  with  voluntary  movements,  Reflex 
Spasm,  Torticollis,  Professional  Cramp,  etc. 

These  are  generally  due  to  some  peripheral  cause,  or  may  result  from 
overtraining  of  the  automatic  sense,  or  in  certain  conditions  arise  in  a 
manner  which  is  at  present  not  clearly  understood. 


480  DISEASES    OF    THE    PERIPHERAL    NERVES. 


I.    TETANY. 

A  light  form  of  attack  arising  generally  from  diarrhoea,  cold,  and  con- 
stipation, and  sometimes  making  its  appearance  during  lactation.  There 
is  usually  some  formication  of  the  palms  or  soles,  and  an  awkwardness  in 
the  movements  of  the  hands  and  feet,  which  is  afterwards  followed  by  a 
firm  tonic  contraction  of  the  muscles  of  either  of  these  parts.  The  flexors 
are  usually  contracted,  so  that  the  hand  is  curved,  or  all  the  fingers  closed. 
A  more  decided  contraction  may  flex  the  forearm  on  the  arm.  The  foot 
may  be  also  affected,  a  condition  of  talipes  resulting,  or  the  back  part  of 
the  leg  may  be  brought  in  apposition  to  the  thigh.  In  marked  forms  the 
upper  and  lower  extremities  are  affected  together,  though  there  is  no  rule 
governing  this,  and  the  spasm  may  be  bilateral  or  unilateral.  The  attack 
rarely  lasts  beyond  an  hour  or  two,  and  in  the  majority  of  instances  relaxa- 
tion may  take  place  in  from  five  to  ten  minutes.  The  spasms  may  come 
on  from  time  to  time,  being  separated  by  greater  or  less  intervals.  They 
are  entirely  uncontrolled  by  the  will,  and  the  patient  cannot  open  his  fin- 
gers when  they  are  thus  contracted.  In  more  severe  forms  the  muscles  of 
the  trunk  or  face  become  involved.  Contraction  of  the  ocular  muscles, 
laryngeal  spasm,  trismus,  or  vesical  spasm  are  examples  of  more  violent 
action.  The  spasms  seem  to  be  produced  when  pressure  is  made  upon  a 
nerve-trunk  or  muscular  belly,  and  there  is  loss  of  tactile  sensibility  asso- 
ciated with  neuralgic  pain  in  the  main  nerve-trunk  of  the  convulsed  limb. 

Tetany  differs  from  true  tetanus  from  the  fact  that  the  spasms  affect  the 
limbs,  that  they  are  intermittent  in  character,  and  that  there  are  intervals 
of  relaxation.  Petit-mal  sometimes  resembles  this  condition,  but  there  is 
always  some  loss  of  consciousness. 

II.    FUNCTIONAL  SPASM  WITH  VOLUNTARY  MOVEMENTS. 

Mitchell1  reports  some  cases  of  functional  spasm,  which  somewhat  resem- 
bles the  so-called  tetany.  The  spasm  appeared  during  the  exercise  of  a 
voluntary  act ;  they  occur  with  the  act  of  laughing,  chewing,  and  talk- 
ing, and  evidently  depend  upon  functional  derangement  of  muscles  inner- 
vated by  the  first  cervical  and  spinal  accessory  nerves.  In  one  case  the 
head  was  drawn  back,  and  the  spine  bowed  so  that  the  patient  was  jerked 
into  a  squatting  posture,  the  gastrocnemius  being  finally  affected. 

In  other  cases  the  spasms  occurred  when  the  individual  began  to  walk. 
In  still  other  cases  there  was  a  rhythmical  motion  when  the  patient 
attempted  any  simple  voluntary  action.  These  Weir  Mitchell  called 
"pendulum  spasms,"  the  number  of  twitches  averaging  160  per  minute, 
and  recurring  witli  great  regularity. 

Bamberger1  reports  a  case  which  resembled  spasm  of  another  kind,  of 
which  I  shall  presently  speak.  Whenever  the  child  was  held  in  the  stand- 

1  Am.  Journ.  Med.  Sciences,  Oct.  1876. 

2  Quoted  by  Handfield  Jones,  Functional  Nervous  Disorders. 


REFLEX    SPASM.  481 

ing  posture  his  legs  were  drawn  up,  and  agitated  by  choreoid  spasms,  the 
spine  and  neck  being  twisted  and  contracted  at  the  same  time ;  but  when 
he  was  placed  upon  his  back  these  movements  ceased. 


III.    REFLEX  SPASM. 

Under  this  head  may  be  classed  a  long  list  of  local  convulsive  move- 
ments dependent  upon  a  variety  of  causes.  Sometimes  there  are  worms 
in  the  intestinal  canal,  and  at  others  a  condition  of  irritability  of  the  geni- 
tals ;  while  peripheral  irritations  of  many  kinds  enter  into  the  etiology  of 
the  spasm. 

I  may  illustrate  the  occurrence  of  one  form  of  spasm  by  the  following 
cases  : — 

I.  A  boy,  7  years  old,  seen  at  the  request  of  Dr.  Sayre,  was  well 
nourished,  with  rosy  cheeks  and  well-rounded  muscles  of  the  upper  ex- 
tremities. His  morbid  condition  had  existed  from  birth,  and  he  possessed 
a  congenital  phimosis,  the  prepuce  being  firmly  fastened  over  the  glans, 
and  the  preputial  orifice  was  very  small  and  surrounded  by  a  rigid  ring  of 
toughened  skin.  On  entering  the  room  I  was  struck  by  the  extraordinary 
restlessness  and  activity  of  the  child.  He  was  lying  on  the  bed,  and  his 

Fig.  53. 


Reflex  Spasm  from  Genital  Irritation. 

lower  limbs  AA'ere  drawn  up  and  agitated  by  irregular  spasms.  The 
arms  were  also  convulsed,  and  their  movements  were  distinctly  choreic. 
When  held  upright  the  child  was  unable  to  stand,  not  from  any  psuv>N. 
but  from  the  apparent  loss  of  coordinating  power,  the  legs  becoming  rigid, 
and  the  toes  of  both  feet  adducted,  more  particularly  the  left.  The  child 
was  unable  to  speak,  but  attracted  the  attention  of  those  around  him  by 
queer  sounds.  His  face  was  distorted,  just  as  we  often  see  it  in  old  cho- 
reic patients,  but  there  was  no  evidence  of  imbecility.  I  did  not  infer 
that  there  was  any  mental  trouble,  except  a  preponderance  of  emotional 
disturbance,  the  boy  being  very  fearful  that  he  was  to  be  hurt.  Upon 
interrogating  I  found  that  he  was  quiet  during  sleep,  that  his  appetite  was 
good,  and  that  there  was  no  irregularity  or  disturbance  of  the  functions  of 
the  bowels  or  bladder.  The  penis  was'  not  so  sensitive  as  I  had  expected 
to  find  it  from  Dr.  Sayre's  description  of  previous  cases.  Titillation  did 
not  produce  immediate  erection,  nor  any  increase  of  the  spasmodic  move- 
ments. On  taking  him  upon  my  lap  the  thighs  and  legs  were  immediately 
drawn  up  ;  there  was  no  evident  pain  produced  by  pressure  on  the  spine. 
31 


482  DISEASES    OF    THE    PERIPHERAL    NERVES. 

II.  Rosa  A.,  5  years  old,  very  pale  and  delicate.  Like  one  of  Dr. 
Sayre's  cases,  tins  child  was  almost  asphyxiated  when  born,  and  it  was 
nearly  ten  minutes  before  she  was  resuscitated.  A  year  after  birth  she 
contracted  scarlet  fever,  but  no  other  trouble  supervened.  After  birth  it 
was  noticed  that  there  was  want  of  power  in  the  lower  extremities.  She 
was  entirely  unable  to  stand,  and  as  soon  as  she  was  held  in  an  upright 
|X)sition  her  legs  became  stiff.  Her  intelligence  was  unaffected,  and  she 
did  not  suffer  pain  in  any  part  of  the  body. 

Present  Condition — The  legs  are  well  proportioned,  and  there  is  no 
atrophy.  The  temperature  of  either  limb  is  not  lowered,  but  there  is 
slight  hypenesthesia.  When  held  in  an  upright  position  by  her  father, 
who  accompanied  her,  the  legs  become  rigid,  the  toes  cross  each  other, 
and  one  foot  seems  inclined  to  cover  its  fellow.  With  this  rigidity  there 
are  irregular  convulsive  movements.  There  is  a  marked  contraction  of 
the  sural  muscles,  which  draw  up  the  heels,  producing  a  double  talipes. 
When  laid  upon  her  back  the  thighs  are  flexed  upon  the  pelvis,  and  this, 
her  father  states,  is  her  position  at  night.  At  this  time  the  head  is  drawn 
back  and  downwards  by  firm  contraction  of  the  trapezius  and  other  mus- 
cles of  the  neck.  An  examination  of  the  genitals  disclosed  a  very  large 
cyanotic  clitoris,  which  was  quite  erect.  There  was  no  history  of  worms. 
Unfortunately,  for  it  was  a  dispensary  case,  the  father  would  not  allow 
anything  to  be  done  in  the  way  of  surgical  interference. 

A  form  of  reflex  spasm  of  the  eyelids  was  reported  by  Von  Graefe,1 
which  rendered  the  patient  helpless,  for  he  was  unable  to  go  about  alone. 
There  was  no  pain  produced  on  pressure  in  the  course  of  the  fifth  nerve ; 
but  when  pressure  was  made  on  the  glosso- palatine  arch  on  the  left  lower 
jaw,  the  spasm  ceased  at  once,  and  the  patient  could  open  his  eyes.  A 
putrid  ulcer  was  found  at  this  locality,  which  acted  as  a  centre  of  irritation 
upon  the  gustatory  nerve. 

IV.     FACIAL  SPASM  WITHOUT  PAIN. 

A  form  of  facial  spasm  not  connected  with  voluntary  motorial  move- 
ment is  occasionally  met  with,  the  orbicularis  palpebrarum  or  buccinator 
being  affected  alone,  or  all  the  muscles  of  the  face  supplied  by  the  portio 
dura  being  convulsed.  The  trouble  differs  from  epileptiform  tic  for  the 
reason  that  it  is  unaccompanied  by  pain.  I  have  been  so  fortunate  as  to 
see  two  of  these  cases.  One  was  that  of  a  gentleman  aged  56,  who  suffered 
an  almost  constant  spasm  of  the  orbicularis  of  the  eye,  which  was  always 
increased  when  he  was  fatigued.  The  eye  would  become  red,  and  there 
was  usually  a  discharge  of  tears,  which  were  unable  to  find  their  way  into 
the  lachrymal  duct,  and  consequently  ran  on  the  cheek.  A  case  pre- 
sented at  the  American  Neurological  Society  by  Dr.  Hammond  suffered 
from  violent  unilateral  spasm  of  all  the  muscles  of  the  face,  which  came  on 
every  two  or  three  minutes. 

1  Schmidt's  Jahrbuch.,  vol.  127,  p.  30;  reported  by  H.Jones,  p.  390. 


TORTICOLLIS.  483 

V.     TORTICOLLIS. 

The  sterno-cleido-mastoid  muscle  may  be  the  seat  of  a  spasmodic  con- 
traction. This  condition  may  be  preceded  by  peripheral  trouble,  such  as 
dentition,  which  was  the  cause  in  one  of  Romberg's  cases,  or  by  such  gen- 
eral diseases  as  rheumatism.  One  case,  which  was  seen  by  Dr.  White 
and  myself,  was  preceded  by  chorea,  and  another,  that  I  saw  at  the  New 
York  State  Hospital  for  Diseases  of  the  Nervous  System,  was  due  to  general 
ana?mia.  In  both  these  cases,  as  well  as  in  others  I  have  observed,  the  head 
was  bent  forward  and  the  chin  pulled  downward.  In  one  case,  that  of  the 
elderly  woman  seen  at  the  nervous  hospital,  the  spasms  were  intermittent. 
Radcliffe  reports  a  case  which  somewhat  resembles  this.  The  muscles 
of  the  neck  were  tender  and  the  seat  of  soreness,  and  the  movements 
were  attended  by  pain.  The  spasms  are  usually  increased  by  emotional 
excitement,  but  subside  during  sleep.  The  notes  of  my  case  are  the  fol- 
lowing:— 

M.  A.  A.,  aged  56,  U.  S.  Came  to  the  hospital  Oct.  29,  1872.  Her 
present  trouble  began  five  years  ago  in  a  very  gradual  manner.  There  are 
now  marked  clonic  spasms  of  the  muscles  of  the  anterior  part  of  the  left 
side  of  the  neck.  With  their  intermitting  contraction,  there  is  some  pain 
at  the  lower  insertion  of  the  sterno-cleido-mastoideus  muscle ;  the  trapezius 
is  also  the  seat  of  spasmodic  contraction.  There  is  headache,  and  pain  at 
the  upper  part  of  the  cord.  Patient's  expression  anxious  and  excited. 
Galvanism  to  muscles  and  spine,  and  zinci  phosphidi  gr.  ^  t.  i.  d.  Pa- 
tient complains  of  dizziness  and  constipation. 

The  muscles  concerned  in  this  form  of  disease  are  the  sterno-cleido- 
mastoideus,  complexus,  trapezius,  and  levator  anguli  scapulae. 

Pathology Weir  Mitchell  has  divided  the  conditions  under  which 

spasms  of  this  kind  may  occur  into  three  groups  : — 

1.  "Those    in  which    the   functional  activity  of   a   muscle  or  set  of 
muscles  gives  rise  at  times  to  an  exaggeration  of  the  motion  involved 
naturally,  and  sometimes  also  to  a  more  or  less  spasmodic  activity  in 
remoter  groups. 

2.  "  Those  in  which  the  functional  action  of  one  group  results  only  in 
sudden  and  possibly  in  prolonged  acts,  tonic  or  clonic,  in  remote  groups 
of  muscles  not  implicated  in  the  original  movement. 

3.  "  Those  in  which  standing  or  walking  occasions  general  and  disor- 
derly motions  affecting  the  limbs,  trunk,  face,  and  giving  rise  to  a  general 
and  uncontrollable  spasm  without  loss  of  consciousness." 

The  central  condition  is  one  of  great  reflex  irritability ;  certain  forms 
of  repeated  irritation  producing  an  activity  of  the  motor  centre  which 
results  in  an  abnormal  increase  in  reflex  susceptibility. 

Treatment Agents  which  lower  the  excitability  of  voluntary 

muscular  action  are  to  be  adopted.  Of  these  I  know  of  no  better  drug 
than  gelsemium  sempervirens  (F.  50),  conium  (F.  51),  musk,  assafcetida, 
or  valerian  (FF.  52,  53,  54).  Rest,  and  removal  of  the  peripheral 
irritation,  should  the  spasm  be  of  reflex  origin,  and  the  ether  spray  to  the 


484  DISEASES    OF    THE    PERIPHERAL    NERVES. 

spine,  are  to  be  resorted  to;  and  at  the  same  time  various  measures  which 
improve  the  individual's  general  condition  are  in  order.  If  all  of  these 
drugs  I  have  mentioned  be  powerless  to  subdue  the  excitable  condition  of 
the  muscles,  I  prefer  profound  brominization,  which  sometimes  controls 
the  movements.  Myotomy  in  torticollis  has  not  proved  itself  to  be  a 
successful  operation,  and  so  I  do  not  recommend  it.  In  other  conditions, 
such  as  adherent  prepuce,  an  operation  is  the  only  method  that  promises 
a  cure.  Galvanism  and  faradism  have  proved  successful  in  the  hands  of 
many,  and  their  use  is  often  attended  by  extremely  beneficial  results.  The 
hypodermic  injections  of  the  alkaloids  sometimes  succeed  when  all  other 
remedies  fail  (FF.  30,  59,  GO,  61,  91,  92). 


PROFESSIONAL  CRAMP. 

Synonyms. — Writer's  cramp,  Dancer's  cramp,  Telegrapher's  cramp ; 
Dyskine'sie  professionelle ;  Melker-krampf,  Schuster-krampf,  Nahekrampf. 

This  very  interesting  condition,  which  follows  the  overtraining  of  groups 
of  muscles,  is  found  among  all  who  engage  in  occupations  which  require  the 
exercise  of  particular  voluntary  muscles  of  the  upper  and  lower  extremi- 
ties to  an  excessive  degree.  Among  these  individuals  such  protracted 
muscular  action,  especially  when  of  a  delicate  kind,  is  likely  to  be  followed 
by  spasmodic  movements  such  as  would  come  under  the  first  group  of 
Mitchell. 

It  is  the  first  of  the  above  varieties  that  at  present  interests  us  the  most. 

WRITER'S  CRAMP  is  the  form  of  hyperkinesis  with  which  we  are  the 
most  familiar,  and  it  is  difficult  to  fail  in  recognizing  its  true  character. 
After  continued  and  fatiguing  use  of  the  pen  the  hand  may  become  at 
first  tired ;  afterwards  the  patient  suffers  from  sharp  pains  which  run 
from  the  hand  up  the  arm,  while  dull  pains  seated  in  the  ball  of  the 
thumb,  the  dorsal  aspect  of  the  fingers,  the  wrist,  or  at  the  exposed  por- 
tion of  the  ulnar  nerve  at  the  elbow,  are  to  be  found  as  well.  His  first 
intimation  may  be  a  certain  tired  feeling,  or,  as  a  very  intelligent  patient 
under  my  care  expressed  it,  "  The  first  idea  of  my  trouble  came  from  the 
feeling  that  1  had  an  arm.  My  mind  was  directed  to  it,  and  whether 
resting  or  at  work,  it  felt  like  a  clumsy  part  of  my  body."  If  the  indi- 
vidual carefully  forms  his  words,  or  if  he  "  writes  with  his  fingers" — a  bad 
habit  which  schoolboys  have,  and  which  sometimes  continues  through 
life — the  trouble  is  much  more  probable  than  when  he  uses  his  whole 
hand  in  guiding  his  pen.  He  may  find  after  a  while  that  when  he 
attempts  to  write,  the  hand  will  fly  upwards  as  the  result  of  a  spasm  of  the 
extensors  and  other  muscles  on  the  dorsal  and  ulnar  side  of  the  forearm, 
so  that  it  is  often  impossible  to  form  more  than  one  or  two  words  of  a 
note  before  the  trouble  begins. 

This  impaired  writing  power  may  exist  to  a  lighter  degree ;  but  when  the 
individual  persists  in  his  attempts,  the  convulsion  is  certain  to  take  place. 
A  light  tonic  spasm  of  the  abductor  minimi  digit!  may  occur  when  the 


PROFESSIONAL    CRAMP.  435 

little  finger  is  separated  from  its  fellows,  and  this  is  sometimes  an  early 
sign  of  the  disease.  He  may  educate  the  left  hand  to  do  the  work  of  the 
right,  and  after  a  while  may  learn  to  use  it  in  a  satisfactory  manner  ;  but 
very  soon  this  too  becomes  affected,  and  he  can  write  with  neither  hand. 
Other  muscular  movements  are  freely  performed,  and  even  some  which 
closely  resemble  that  of  holding  the  pen.  Trembling  sometimes  super- 
venes, while  fibrillary  muscular  contractions  are  suggestive  of  the  confirmed 
disease.  As  is  the  case  in  sclerosis,  the  disorderly  movements,  or  the 
spasms,  seem  to  be  intensified  when  the  patient  attempts  to  write  in  the 
presence  of  a  looker-on,  and  he  usually  makes  sad  work. 

The  fingers,  forearm,  and  wrist  sometimes  become  the  seat  of  lost 
power,  and  this  is  marked  in  the  three  first  fingers  of  the  right  hand,  and 
the  pronators  and  supinators  lose  power.  Sensation  is  rarely  lost  or 
impaired.  In  some  cases  the  flexors  of  the  hand  and  the  small  muscles 
of  the  thumb  are  so  weak  that  the  point  of  the  pen  cannot  be  kept  in 
contact  with  the  paper,  as  the  extensors  seem  to  act  independently. 

The  same  form  of  cramp  affects  the  thumbs  and  fingers  of  telegraphers, 
so  that  their  work  eventually  becomes  an  impossibility.  Onimus1  pre- 
sents a  case.  A  telegraphic  operator,  19  years  of  age,  first  experienced 
difficulty  in  making  dots;  " d "  was  made  better  than  "u;"  and  it  was 
found  that  when  a  line  was  first  the  dots  were  more  easily  made ;  but 
letters  like  "h"  or  "p"  were  exceedingly  difficult.2 

Dancers'  cramp  has  also  been  observed.  Schultz3  describes  this  form  of 
disease,  of  which  he  has  seen  three  cases.  It  affects  the  solo  dancers  of 
the  ballet  as  a  rule,  and  the  history  of  one  case  was  the  following : — 

"  The  patient  complained  of  suffering  very  severe  pains  while  dancing. 
Beginning  in  the  soles  of  both  feet,  the  pains  spread  with  increasing 
severity  to  the  calves  of  the  legs ;  they  at  last  became  so  violent  that  her 
feeling  of  security  was  lost,  the  feet  seeming  as  if  made  of  wood.  These 
pains  were  accompanied  with  violent  palpitation  ;  and,  if  she  continued  to 
dance,  she  felt  faint  and  sometimes  lost  consciousness,  the  body  becoming 
quite  rigid.  When  the  pain  and  palpitation  were  less  intense,  the  pain 
continued  after  dancing,  and  ceased  very  gradually,  leaving  some  tender- 
ness of  the  soles ;  on  attempting  again  to  dance  the  suffering  would  recur 
again.  Dr.  Schultz  found,  from  the  examination  of  these  cases,  that  the 
cause  of  the  pain  lay  in  the  pas  performed  on  the  points  of  the  feet,  and  is 
owing  to  exhaustion  of  the  muscles  which  fix  the  metatarsus  and  phalanges 
of  the  great  toe.  The  shoe  worn  by  the  dancer,  without  which  the  ballet 
step  seems  to  be  impossible,  is  made  as  follows  :  The  dancing-shoe  is  made 
rather  wide  ;  the  sole  is  of  soft  leather,  and  shorter  than  the  foot,  reaching 
only  as  far  as  the  posterior  third  of  the  ungual  phalanx  of  the  great  toe. 
The  upper  part,  generally  of  satin,  projects  forward,  and  supplies  the  place 
of  the  deficient  leather  of  the  sole.  This  part  of  the  satin  is  worked  threads, 
so  that  it  may  not  be  torn.  In  the  interior  of  the  shoe,  over  the  leather 
sole,  is  a  layer  of  thin,  firmly-pressed  pasteboard,  either  extending  over 
the  whole  breadth  of  the  anterior  part,  or  limited  to  the  length  of  the 

1  Gaz.  Med.  de  Paris  ;  Chicago  Journal  of  Mental  and  Nervous  Diseases,  July, 
1875. 

2  ( U)  ( d)  ( h ; p.)  3  Wiener  Med.  Wocli. 


486  DISEASES    OF    THE    PERIPHERAL    NERVES. 

great  toe.  In  the  former  case  it  is  carried  back,  gradually  narrowed  as 
far  as  the  heel.  The  leather  sole  and  its  covering  are  lined  with  fine  kid 
leather.  The  heel  part  of  the  shoe  is  quite  soft,  consisting  only  of  satin  ; 
and  the  shoe  is  fastened  above  the  ankle  by  narrow  ribbons.  Without  this 
preparation  the  pointed  step  is  impossible." 

I  have  met  with  the  affection  among  violin-players,  and  within  the  past 
year  have  had  a  patient  under  treatment.  He  had  been  diligently  prac- 
tising a  "  run,"  which  involved  the  necessity  of  complicated  movements  of 
the  fingers ;  and  it  was  his  custom,  on  arising  in  the  morning,  to  spend  a 
half  hour  or  so  in  playing  the  difficult  passage  ;  and  on  the  day  of  the  con- 
cert he  worked  for  several  hours  at  the  same  task,  but  upon  attempting 
to  play  in  the  evening  he  found  it  utterly  impossible  to  do  so,  as  his  fingers 
would  become  rigid  and  refuse  to  obey  the  will.  It  was  some  months  be- 
fore he  could  again  play. 

Onimus,1  in  describing  a  form  of  impaired  power  and  consequent  mus- 
cular atrophy,  which  he  calls  "  professional  muscular  atrophy,"  details  a 
case  which  resembles  somewhat  the  form  of  functional  disease  which  we 
are  considering.  It  begins  by  muscular  cramp,  and  there  is  subsequent 
loss  of  power  with  wasting.  I  therefore  think  we  may  consider  this  affec- 
tion as  a  connecting  link  between  scrivener's  cramp  and  progressive  mus- 
cular atrophy.  He  says  : — 

"  Recently  I  observed  one  case  which  it  was  most  difficult  to  differentiate 
from  progressive  muscular  atrophy,  as  the  atrophied  muscles  were  the  same 
as  those  which  are  the  first  affected  by  this  latter  affection.  They  were 
the  muscles  of  the  thenar  eminence,  and  chiefly  the  adductor  pollicis. 
The  patient  was  an  enameller,  who  had  to  hold  an  object  all  day  between 
his  thumb  and  index  finger.  He  first  got  cramps  in  the  thumb,  which 
suggested  the  idea  of  scrivener's  palsy ;  then  tremor  of  the  thumb,  on  ac- 
count of  the  fibrillary  contractions ;  and,  lastly,  atrophy.  Under  the 
influence  of  treatment  there  was  a  rapid  amendment,  which  showed  that 
the  case  was  really  one  of  professional  muscular  atrophy,  and  not  com- 
mencing progressive  atrophy." 

Causes  and  Pathology — This  spasmodic  affection  follows  the  con- 
tinued use  of  the  muscles  which  are  concerned  in  delicate  muscular  actions; 
and  is  not  only  produced  by  writing,  but,  as  I  have  shown,  by  other  forms 
of  manipulation  requiring  great  delicacy  of  coordination.  The  higher  and 
the  more  complex  is  the  character  of  these  acts,  and  the  more  easily  the  fac- 
ulty to  perform  them  becomes  developed,  so  much  the  greater  is  the  danger 
of  the  disease.  An  act  which  requires  at  first  mental  direction  of  a  superior 
kind,  when  acquired  and  executed  unconsciously,  is  much  more  likely  to 
give  rise  to  this  neurosis  than  one  of  a  grosser  kind,  or  one  which  is  con- 
stantly performed  under  the  active  direction  of  the  will.  For  this  reason 
writer's  cramp  is  much  more  rare  among  those  who  write  and  meanwhile 
compose,  than  among  clerks  or  copyists  who  do  "  machine  work."  Con- 
stant use  of  the  pen  of  this  kind  is  seen  to  be  followed  by  mischief.  Such 

1  London  Lancet,  Jan.  22,  1876. 


PROFESSIONAL    CRAMP.  487 

causes  as  piano-playing  or  violin-playing  are  by  no  means  rare.  A  young 
lady,  sent  to  me  by  my  friend  Dr.  D.  M.  Stimson,  owed  all  her  trouble  to 
a  bad  habit  she  had  contracted  of  reading  novels  while  she  practised  her 
scales.  In  her  case  there  was  extensor  paralysis,  and  some  loss  of  sensa- 
tion, which  remained  after  a  spasmodic  stage. 

The  conditions  then,  with  the  exception  of  paralysis,  are  the  result  of 
an  over-developed  automatism,  and  are  not,  I  am  convinced,  connected 
with  any  central  change,  though  Mr.  Solly1  is  inclined  to  consider  that 
there  is  degeneration  of  the  motor  cells  in  the  upper  part  of  the  cord. 

In  writing  a  familiar  word,  or  collection  of  words,  the  educated  indi- 
vidual does  not  stop  to  form  every  letter,  but  the  pen  is  unconsciously 
guided.  It  is  even  possible  to  talk  while  writing  or  playing  the  piano,  and 
equally  complex  feats  are  performed  while  the  mind  is  not  engaged.  In 
many  of  these  acts  the  volition  is  directed  in  other  channels,  or  is  behind 
the  muscular  action.  The  pen  travels  in  advance  of  the  mind  ;  and  should 
this  state  of  things  be  so  exaggerated  as  to  become  more  than  a  phase  of 
the  ordinary  automatism  which  enters  into  the  performance  of  many  of  the 
functions  of  daily  life,  there  remains  a  condition  of  disordered  and  height- 
ened activity  which  is  uncontrolled  by  the  will,  and  is  symptomatized  by 
the  spasms  of  which  I  have  spoken.  A  more  advanced  condition  con- 
sists in  exhaustion  of  the  motor  cells  at  the  upper  part  of  the  cord,  and  as 
a  result  we  find  loss  of  power  and  occasionally  atrophy.  Poore8  does  not 
believe  in  the  central  organic  origin  of  the  disease  ;  but  Solly,3  Smith,4  and 
Hammond5  take  this  view  of  the  case. 

Among  23  cases  which  I  have  seen,  the  occupation  of  the  individuals 
was  as  follows  : — 

Clerks      .         .         .         .14  Stenographer     .         .         .  1 

Engraver          ...       1  Musicians  ....  2 

Lawyers  ....       2  Type-setter        ...  I 

Clergymen        ...       1  Cigar-maker       ...  1 

As  it  will  be  seen,  the  patients  were  all  men.  They  were  all  between 
the  ages  of  30  and  60,  but  I  do  not  believe  this  latter  fact  has  very  much 
importance. 

Diagnosis Progressive  muscular  atrophy  may  be  mistaken  for  the 

paralytic  form,  but  when  it  is  remembered  that  the  paralysis  precedes  the 
atrophy  (should  such  tissue-change  take  place),  and  that  progressive 
muscular  atrophy  is  rarely  so  limited,  there  is  no  reason  why  the  real 
nature  of  the  trouble  should  not  be  recognized.  Neuralgia  of  the  cervico- 
brachial  variety  is  a  common  symptom,  and  its  real  significance  may  not 
be  detected ;  the  subsequent  element  of  spasm,  tremor,  or  paralysis  will, 
however,  remove  any  doubt  from  the  mind  of  the  observer. 

1  Surgical  Experiences,  London,  1865,  p.  20.5. 

2  Practitioner,  June,  July,  and  August,  1873. 

t  Op.  cit.  4  Lancet,  March  27,  18G9. 

5  Op.  cit.,  p.  790. 


488  DISEASES    OF    THE    PERIPHERAL    NERVES. 

Prognosis If  the  individual  gives  up  the  occupation  which  has  pro- 
duced the  affection,  there  is  no  reason  why  he  should  not  recover,  provided 
the  disease  has  not  become  confirmed,  and  even  in  this  form  Jaccoud1 
speaks  of  a  rare  temporary  amelioration.  It  has  been  my  experience  tlmt, 
if  taken  in  hand  promptly,  the  patient  may  be  cured.  Sixteen  of  tli«  -<• 
cases  were  absolutely  cured,  and  continued  so  as  long  as  they  refrained 
from  their  work.  Two  were  improved,  but  upon  beginning  the  pursuit  of 
their  calling  had  relapses.  The  remainder  were  of  the  paralytic  variety, 
and  are  now  under  treatment. 

Treatment Rest  and  electricity  are  the  means  at  our  command. 

A  galvanic  current  is  found  to  be  the  most  beneficial,  and  the  electrodes 
should  be  so  small  as  to  include  but  one  muscle  at  a  time  in  the  circuit. 
The  current  must  be  mild,  or  it  will  only  aggravate  the  disease.  Besides 
this  application  to  special  muscles,  one  pole  may  be  placed  at  the  nape  of 
the  neck,  and  the  other  to  the  muscles  of  the  hand  and  forearm. 

A.  W.,  aged  38.  The  patient  had  followed  the  occupation  of  clerk  for 
several  years,  and  had  assiduously  worked  at  his  desk  for  many  hours 
in  the  day.  Two  weeks  before  I  saw  him  he  noticed  an  impairment 
in  his  writing  power,  and  this  consisted  in  an  inability  to  write  without 
the  occurrence  of  a  convulsive  contraction  of  the  extensors  of  his  right 
forearm,  by  which  the  pen  flew  from  the  paper.  This  did  not  occur  at 
the  moment  of  writing,  but  after  a  few  words  had  been  finished.  He  tried 
to  keep  the  hand  steady  by  the  influence  of  the  will,  but  all  his  efforts 
were  ineffectual.  When  he  attempted  to  hold  the  point  of  any  small  ob- 
ject, such  as  a  stick  or  pencil,  against  the  surface,  the  same  spasm  would 
occur.  There  was  no  wasting  of  the  muscles,  pain,  or  other  symptom. 
I  determined  to  try  galvanism  combined  with  manual  exercise,  and  the 
internal  application  of  strychnia  in  doses  of  g^th  of  a  grain.  Galvani/a- 
tion  of  the  flexors  of  the  forearm  and  of  the  small  muscles  of  the  hand  was 
made,  and,  at  the  same  time,  the  positive  |x>le  was  held  for  a  few  minutes 
at  the  najxi  of  the  neck.  He  was  directed  to  procure  the  round  of  a  chair 
with  which  to  exercise.  Galvanization  was  persevered  in,  although  the 
progress  was  very  slow.  At  first  he  could  not  write  more  than  two  words 
(almost  illegibly)  ;  but  as  he  grew  better,  these  spasms  disappeared. 

Three  seances  a  week  kept  up  for  a  period  of  about  three  months  effected 
such  an  improved  condition  that  he  was  finally  discharged  at  the  end  of 
that  time. 

Strychnia  and  iron,  or  conium  (FF.  8,  9,  10,  48,  51,  72,  82),  are 
remedies  which  may  IK-  used  in  conjunction.  The  ether  spray  apparatus 
does  great  good,  and  I  have  occasionally  benefited  my  patients  by  fasten- 
ing the  hand  in  an  immovable  apparatus  or  splint.  Absolute  cessation  of 
the  particular  work  which  gave  rise  to  the  malady  is  to  be  insisted  upon, 
and  no  benefit  will  result  from  any  form  of  treatment  unless  this  command 
of  the  physician  is  re*j)ected. 

When  the  patient  attempts  writing  anew  he  should  provide  himself 
with  a  pen  having  a  cork  holder,  and  this  may  be  purchased  from  any 

1  Op.  cit.,  p.  302. 


PROFESSIONAL    CRAMP.  489 

good  stationer.  He  should  change  his  system  of  penmanship  and  acquire 
the  so-called  free  hand  style,  in  which  the  fingers  are  engaged  only  in 
holding  the  pen,  and  the  other  motions  are  performed  by  the  muscles  of 
the  forearm.  The  attempt  at  "  shading"  the  lines  should  not  be  made, 
but  he  should  endeavor  to  adopt  the  round  hand  and  avoid  "pot  hooks" 
and  "  up  and  down"  strokes  as  much  as  possible. 

Sea  air.  salt  baths,  and  a  change  of  habits  and  scene  are  all  fraught 
with  benefit. 

I  do  not  consider  tenotomy  advisable  except  in  extreme  instances. 


FOKMULJ1. 

(ADULT  DOSES.) 


1. 

R.     Tr.  aconit.  rad.  3j-3ij; 

Sodii  bromidi  3iss; 

Aquae  menth.  pip.  ad  giv M. 

Sig-  5j  t.  i.  d. 


2. 

R.    Tr.  digital.  5 iij  ; 

Syr.  papav., 

Elixir  cura9oa,  aa  |ij M. 

Sig-  3j  at  a  dose. 


3. 

R.    Chloral,  hydrat.  gj  ; 

Ess.  menth.  pip.  q.  s. ; 

Syr.  tolutan., 

Mucil.  aoac.,  aa  3ij M. 

Sig.  3j  at  a  dose,  well  diluted. 


4. 

R.     Chloral,  hydrat., 

Calcii  bromidi,  aa  3j  > 

Syr.  limonis  ^ij  ; 

Aquas  ad  ^iv — M. 
Sig.  Jj  at  a  dose. 

5. 

R.     Dragee  ergotin  (Bonjean),  (gr.  v.),  no.  xx. 
Sig.  One  at  a  dose. 


FORMULA.  491 

6. 

R.    Fl.  ext.  ergotae  £ij  ; 

Sodii  bromidi  §iss  ; 

Aquas  camphorae  ad  Jfiv. — M. 
Sig.  A  teaspoonful  every  4  hours. 

7. 

R.    Acidi  hydrocyanic!  dil.  n^  xx-xxxvj  ; 

Aq.  ext.  ergotse  3J — M. 
Ft.  massa  et  divid.  in  capsul.  no.  xij. 
Sig.  One  every  3  hours. 


R.     Stryeh.  sulph.  gr.  ss-j  ; 

Cinchonas  sulph.  5j  5 

Tr.  ferri  chlor.  3V  > 

Acidi  phosph.  dil., 

Syr.  limonis,  aa  Jij — M. 
Sig.  A  teaspoonful  in  water  at  a  dose. 

9. 
Hammond's  Solution. 

R.     Stryeh.  sulph.  gr.  ss-j  ; 

Quiniae  sulph., 

Ferri  pyrophos.,  aa  3j  5 

Acidi  phos.  dil., 

Syr.  zingib.,  aa  % ij — M. 
Sig.  A  teaspoonful  in  water  at  a  close. 

10. 

R.     Ext.  nucis  vom.  gr.  viij  ; 

Quin.  sulph.  3j  '•> 

Ferri  redacti  gr.  xxx — M. 
Ft.  massa  et  divid.  in  pil.  no.  xxx. 
Sig.  One  after  eating. 

11. 

R.     Sol.  strych.  sulph.  (gr.  j-Jij)  gij 

Ferri  dialysat.  Jiss; 

Aquae  flor.  aurantii  ad  s'\v — M. 
Sig.  A  teaspoonful  at  a  dose. 


FORMULAE. 


12. 

R.     Ferri  carbonat.  sacch.  5'j  ; 

Cinchon.  sulph.  gr.  xxiv. — M. 
Divid.  in  chart,  no.  xij. 
Sig.  One  t.  i.  d. 

13. 

R.     Zinci  oxidi  5J  ; 

Confectio.  rossB  q.  s — M. 
Ft.  massa  et  divid.  in  pil.  no.  xxx. 
Sig.  One  t.  i.  d. 

14. 

R.    Sol.  potass,  arsenitis  5ij  ; 

Quinism  sulph.  5$s ; 

Acidi  sulph.  aromat.  q.  s. ; 

Aqua?  anisi  ^iv M. 

Sig.  A  teaspoonful  every  4  hours. 

15. 

R.     Sol.  acidi  hydrobromici, 

Elixir  simplicis,  aa  3ij — M. 
Sig.  A  teaspoonful  before  each  meal. 

16. 

R.     Quinine  sulph.  5.)  » 

Sol.  acidi  hydrobromici  ^iij  ; 

Aquae  campliorae  ad  £iv M. 

Sig.  A  teaspoonful  three  times  a  day,  in  a   tumblerful 
of  water. 

17. 

R.     Potass,  iodidi  5'j  ; 

Potass,  nit  rat.  5vj  5 

Syr.  scillje  3j  ; 

Spts.  ai union,  acetat.  ad  Jiv M. 

Sig.  A  teaspoonful  every  4  hours. 

18. 

R.    Potass,  acetat.  5vj  ; 

Infus.  digitalis  Jviij M. 

Sig.  A  dessertspoonful  three  times  a  day. 


FORMULAE.  493 

19. 
Bayhy's  Pill 

R.    Pil.  hydi-arg.  massae, 

Pulv.  scilhe, 

Pulv.  digital.,  aa  gr.  xxiv. — M. 
Ft.  massa  et  divid.  in  pil.  no.  xxiv. 


20. 

R .    Hydrarg.  bichlor.  gr.  ss  ; 

Potass,  iodid.  3J  ; 

Tr.  cinch,  co.  Jiv — M. 
Sig.  A  teaspoonful  three  times  a  day. 

21. 

R.     Tr.  ferri  chlor., 

Tr.  digitalis,  aa  ^ss — M. 
Sig.  Ten  to  twenty  drops,  in  water,  three  times  a  day. 


22. 

R.     Elaterii  gr.  iv  ; 

Ext.  nucis  vom.  gr.  iij  ; 

Confectio.  rosae  q.  s — M. 
Ft.  massa  et  divid.  in  pil.  no.  xij. 

23. 

R.     Sodii  bromidi, 

Ammon.  bromidi,  aa  3ss; 

Chloral,  hydrat.  3YJ ; 

Tr.  aconiti  rad.  Jiss ; 

Aquae  menth.  pip.  ad  £iv — M. 

Sig.  A  teaspoonful  three  times  a  day,   or  ot'tnicr  it' 
required. 


24. 

R .     Phosphori  gr.  ij  ; 

Ol.  amygdala?  dulc.  3j  '•> 
Ess.  menth.  pip.  q.  s. ; 
Mucil.  acac.  £vj — M.      ,. 

Sig.  A  teaspoonful  after  eating. 


494  FORMULAE. 

25. 
Thompson's  Solution. 

R.     Phosphor!  gr.  ss-iss  ; 

Alcohol  absol.  q.  s.  ut  dis.  ; 

Ess.  menth.  pip.  q.  s.  ; 

Glycerin*  ad  Jiv  __  M. 
Sig.  A  teaspoonful  after  eating. 

26. 

R.    Phosphori  gr.  ss-j  ; 

Sevi  gr.  c  —  M. 
Divid.  in  pil.  no.  xxv. 
Sig.  One  after  eating. 

27. 

R.     Zinc,  phosphidi  gr.  iv  ; 

Confectio.  rosae  gr.  xxiv.  —  M. 
Ft.  massa  et  divid.  in  pil.  no.  xij. 
Sig.  One  after  eating. 

28. 

R.     Strych.  sulph.  gr.  ss-j  ; 

Acidi  muriatici  dil.  Jvj  ; 

Aquae  ad  giv  —  M. 
Sig.  3j  t.  i.  d. 

29. 

R.    Strych.  sulph.  gr.  ss-j  ; 

Acidi  phosph.  dil.  ^ij  ; 

Syr.  simplicis  ad  siv.  —  M. 
Sig.  3j  t.  i.  d. 

30. 
JJartholow's  Injection  for  Hypodermic  use. 

R.     Strych.  sulph.  gr.  ij  ; 

Aq.  destil.  vel  aquae  cerasi  3J  —  M. 


81. 

R.     Pepsini  sacch.  3vj  5 
Acidi  muriatici  dil., 
Tr.  nucis  vom.,  aa  £ss  ; 
Aquae  cinnamomi  ad  ^iv  __  M. 

Sig.  A  teaspoonful  after  each  meal. 


FORMULAE.  495 


32. 


R.    Ol.  morrhuae, 

Ext.  malti  (Loeflund),  aa  |iv M. 

Sig.  A  tablespoonful  three  times  daily. 

33. 

R.    Bismuth,  subcarb., 

Pepsini  sacch.,  aa  ^ss  ; 

Pulv.  aromatici  ad  £iv M. 

Divid.  in  chart,  no.  xxiv. 
Sig.  One  t.  i.  d.  after  eating. 

34. 

R.     Pepsini  sacch., 

Pulv.  carb.  ligni,  aa  Jss — M. 
Divid.  in  chart,  no.  xxiv. 
Sig.  One  three  times  a  day  after  eating. 


R.    Antimon.  tartrat  gr.  j  ; 

Aquas  ^iv. — M. 

If  emesis  is  desired,  give  one  tablespoonful  every  half  hour  till  vomiting 
is  produced  ;  or,  if  continued  depressing  effect  is  desired,  a  teaspoonful  every 
hour  or  two. 

36. 

R.     Tr.  verat.  virid.  3iJss  > 

Aq.  menth.  pip.  ad  £iv — M. 

Sig.  One   teaspoonful  every  two  hours,  or  oftener  if 
needed. 

37. 

R.     Phosphori  gr.  j  ; 

Ol.  morrhuas  Oj — M. 
Sig.  A  tablespoonful  at  a  dose. 

38. 

R.     Sodii  bromidi  ^iss  ; 

Aquae  camphorae, 

Tr.  lupulin.,  aa  3U- — M. 
Sig.  A  teaspoonful  at  a  dose. 


496  FORMULAE. 

39. 

R.     Tr.  cannabis  indicae  5U  » 

Aq.  flor.  aurantii  ad  sij. — M. 
Sig.  A  teaspoonful  at  a  dose. 


40. 

R.    Ferri  et  ammon.  citratis  3$s  ; 

Tr.  cinch,  co., 

Tr.  gentianae  co.,  aa  3y  5 

Aquae  ad  Jviij — M. 
Sig.  A  dessertspoonful  ter  in  die. 


41. 


R.    Magnes.  sulph.  ^j  5 

Infus.  senna?  giv  ; 

Int'us.  caffeae  3ij M. 

Sig.  A  wineglassful  to  be   taken  every  morning,  or 
oftener  if  required. 


42. 

R.    Syr.  ferri  iodid.  5vj  ; 

Syr.  glycyrrhizaa  Jiv M. 

Sig.  Half  to  a  full  tejispoonful  after  eating. 

43. 

R.     Acidi  arsenici  gr.  j  ; 

Pulv.  nigr.  pip., 

Ferri  redacti,  aa  gr.  xx  ; 

Ext.  gentianae  q.  s. — M. 
Ft.  massa  et  divid.  in  pil.  no.  xx. 
Sig.  One  three  times  a  day. 


44. 

R.     Ext.  belladonnas  gr.  iij— vj  ; 

Zinci  oxidi  gr.  xlviij  ; 

Syr.  simplicis  q.  s M. 

Ft.  massa  et  divid.  in  pil.  no.  xlviij. 
Sig.  One  thrice  daily. 


FORMULA.  497 

45. 

R.     Potass,  ioclidi  £iss  ; 

Vini  sem.  colchici  3ijss  ; 

Potass,  nitrat.  5"j  ; 

Aquae  ^viij M. 

Sig.  A  tablespoonful  three  times  a  day. 

46. 

R.     Sodas  bicarb., 

Sulph.  lot.,  aa  %ss — M. 
Divid.  in  chart,  no.  xx. 
Sig.  One  three  times  a  day. 

47. 

R.     Croton-chloral.  3yss » 
Aquae  rosaa  ^viij — M. 
Sig.  A  tablespoonful  at  a  dose. 

48. 

R.    Protagon. 

Syr.  aurantii  cort.,  aa  ^j. — M. 
Sig.  Thirty  drops  to  a  teaspoonful  three  times  a  day. 

49. 

R .    lodoformi  gr.  xxiv  ; 

Confectio.  rosas  q.  s — M. 
Ft.  raassa  et  divid.  in  pil.  no.  xxiv. 
Sig.  One  thrice  daily,  or  oftener  if  required. 

50. 

R.    Fl.  ext.  gelsemium  semperv.  3iJss> 

Elixir  simplicis  ad  Jiv — M. 
Sig.  One  to  two  teaspoonsful  at  a  dose. 

51. 

R.     Ext.  conii  fl.  (Squibb)  gss ; 

Soclii  bromidi  3 j  ; 

Aquas  cam  phone  ad  ^iv. — M. 
Sig.  Teaspoonful  at  a  dose. 
32 


FORMULA. 

52. 

R.    Tr.  moschi, 

Tr.  lobelias,  aa  3ij  > 

Spts.  etheris  comp.  ad  'ij — M. 
Sig.  A  teaspoonful  at  a  dose. 

53 — (Tanner.) 

R.     Tr.  assafoetidae  3U  > 

Spts.  ammon.  aromatici  3'ij  » 

Tinct.  chirata?  3vy« — M- 

Sig.  GO  drops  in  a  wineglassful  of  water  every  two  or 
three  hours. 


54. 

R.     Elix.  ammonia?  valerianat.  Jfiij  ; 

Chloroformae  3*ss ; 

Aquae  camphorae  ad  ^iv M. 

Sig.  3J  every  3  or  4  hours. 

55. 

R.     Zinci  valerianat., 

Ext.  hyoscyami,  aa  3j — M- 
Ft.  pil.  no.  xl. 
Sig.  One  at  a  dose. 

56. 

R.    Ext.  physostig.  venenos.  gr.  xij. 
Divid.  in  pil.  no.  xxxvi. 
Sig.  One  every  4  hours. 

57. 

R.    Syr.  calei  lactophosph., 

Ext.  malti,  au  3ij M. 

Sig.  A  teaspoonful  every  4  hours. 

58. 

R.    Ferri  bromidi  5'j  ; 

Syr.  lat'tucarii  Jiv M. 

Sig.  Half  to  one  teaspoonf ul  every  3  or  4  hours. 


FORMULA.  499 

59. 
Hypodermic  Injection. 

R.    Atropias  sulph.  gr.  j  ; 

Sol.  Magendie  5J  —  M. 
Filter,      n^v-x. 

60  __  (Bartholow.) 

R  .     Ext.  ergotin.  aq.  5j  > 

Glycerine  3J  ; 

Aquae  Svij  —  M. 
Filter.      Tn,viij  =  gr.  j. 


61. 

R.     Atropiag  sulph.  gr.  j  ; 

Aqua?  3j  ; 

Acid,  salicylic!  q.  s  —  M. 
Filter.     n\,x  =  gr.  ?y 

62. 

R.    Tr.  belladonnas  §ss  ; 

Glycerinaj  3J  ; 

Linim.  sapon.  §iij.  —  M. 
Ft.  linimentum. 

63. 

R.     Tr.  aconiti  rad.  Sij  ; 

Linim.  camph.  comp.  ad  §iv  —  M. 
Ft.  linimentum. 

64. 

R.    Tr.  aconiti  fol., 

Chloroformaa, 

Tr.  capsici,  a  a  Sss  ; 

Linim.  saponis  ad  ^iv.  —  M. 
Ft.  linimentum. 

65. 

R.    Unguent,  veratriae  §j  ; 

Rad.  aconiti  pulv.  5j—  M- 
Use  externally  (with  care). 


500  FORMULA. 

66 (Turnbull.) 

R.    Aconitiae  gr.  ij  ; 

Spt.  rectificati  gtt.  vj } 
Adipis  prep.  Jj — M. 
Rub  a  small  part  on  the  track  of  the  painful  nerve. 

67. 

R.    Chloral-hydrat., 

Camphorae,  aa  3\j ; 

Adipis  ^ss — M. 
Use  locally. 

68 — (Tanner.) 

R.     Camphorae  3j  5 

Ext.  belladonnas  gr.  iv  ; 

Ext.  conii  gr.  xlviij — M. 
Ft.  massa  et  divid.  in  pil.  no.  xlviij. 
Sig.  One,  thrice  a  day. 

69. 
R.    Emulsio  pancreatin.  5i-3ss  after  eating. 

70. 

R.    Ext.  belladonnas  gr.  iv ; 

Ext.  opii, 

Ext.  hyoscyami,  aa  gr.  xij M. 

Ft.  massa  et  divid.  in  pil.  no.  xij. 
Sig.  One  at  a  dose. 

71. 

R.    Ext.  hyoscyami, 

Ext.  conii,  aa  gr.  xxiv — M. 
Ft.  massa  et  divid.  in  pil.  no  xij. 
Sig.  One  or  two  at  a  dose. 

72. 

R.     Strychniae  sulph.  gr.  j  ; 

"Acid  phosphates"  (Horsford), 
Tinct.  cimicifugte  rac.,  aa  5ij — M. 

Sig.  Teaspoonful  at  a  dose. 


FORMULA.  501 

73. 

R.  Syrupi  phosphati  comp.  (calcis,  ferri,  etc.). 
Sig.  Teaspoonful  at  a  dose. 

74. 

R.    Tr.  belladonnas, 

Potass,  iodidi,  aa  Jij  ; 

Aquaa  menth.  pip.  |iv M. 

Sig.  5j  t.  i.  d. 

75. 

R.     Tr.  ferri  perchloridi  ^ss  ; 

Glycerina3  Jj  ; 

Tr.  calumbae  ad  £iv — M. 
Sig.  3J  t.  i.  d. 

76. 

R.    Ext.  belladonna?  gr.  iv  ; 

Ext.  ergotce  aq.  3j  > 

Ferri  sulph.  exsiccat.  Jss — M. 
Ft.  massa  et  divid.  in  capsul.  no.  xij. 
Sig.  One  every  4  hours. 

77. 

R.    Argenti  nitrat.  gr.  vj-viij  ; 

Confectio.  rosas  q.  s — M. 
Ft.  massa  et  divid.  in  pil.  no.  xxiv. 
Sig.  One  after  each  meal. 

78. 

R.    Argenti  nitrat., 

Ext.  belladonnas,  aa  gr.  vj-viij  ; 

Ext.  gentianae  q.  s — M. 
Divid.  in  pil.  no.  xxiv. 
Sig.  One  after  each  meal. 

79. 

R.    Argenti  nitrat.  gr.  vj-viij  ; 

Ext.  nucis  vom.  gr.  xij — M. 
Divid.  in  pil.*no.  xxiv. 
Sis.  One  after  each  meal. 


502  FORMULA. 


80. 


R.     Argenti  phosphat.  (tribasic.)  gr.  viij  ; 

Ext.  quassia?  q.  s — M. 
Ft.  massa  et  divid.  in  pil.  no.  xxiv. 
Sig.  One  after  each  meal. 

81. 

R.     Ext.  belladonna?  gr.  iv  ; 

Ol.  terebinth.  3ij  ; 

Buytri  cacao  q.  s — M. 
Divid.  in  capsul.  no.  xij. 
Sig.  One  t.  i.  d. 

82. 

R.    Tr.  physostig.  venenos.  n^v-x  ; 

Glycerine  5.) » 

Aq.  rosa?  ^iij — M. 
Sig.  At  a  dose. 

83. 

R.    Tr.  aconiti  rad.  n^v  ; 

Chloroform®  n^x; 

Syr.  papav.  Jss. — M. 
Sig.  At  a  dose. 

84. 

R.    Ammon.  bromidi, 

Sodii  bromidi,  au  3j — M. 

Divid.  in  chart,  no.  xlviij.     Put  in  waxed  paper. 
Sig.  Two  at  night,  and  one  in  the  morning. 


85. 

R.    Amyl  nitriti  3".j  ; 

Alcohol,  absol.  ad  ^ij M. 

The  patient  should  be  directed  to  provide  himself  with  a  small  homa-o- 
jwitliic  bottle,  into  which  he  is  to  put  3SS  °f  the  mixture.  When  he  has 
an  aura  of  sufficient  length,  he  may  quickly  empty  the  contents  of  the 
bottle  in  his  handkerchief,  and  apply  it  to  the  nostrils. 


FORMULA.  503 

86. 


R.     Tri-nitro.  glycerini  3ss ; 

Alcohol,  absol.  5vj M. 

Sig.  8-10  drops  three  times  a  day. 


87. 


4 

R.     Camphorae  monobromidi  5ss-3j ; 

Confectio.  rosae  q.  s M. 

Divid.  in  capsul.  no.  xij. 

Sig.  One  every  hour  until  the  effect  is  produced. 


R.     Tr.  cannab.  Ind., 

Tr.  hyoscyami,  a  a  5V  5 

Tr.  conii  3iss-5'ij  5 

Syr.  lactucarii  ad  ^iv M. 

Sig.  Teaspoonful  at  dose. 

89. 

R.  Tr.  nucis  vomicae  3V  > 
Spts.  ammon.  aromatici, 
Tr.  capsici,  aa  3VJ  5 
Aquaa  cam  phone  ad  ^iv. — M. 

Sig.  Teaspoonful  at  a  dose,  in  the  morning. 


R.     Tr.  digitalis  3VJ  ! 

Ferri  dialysat.  3j  ; 

Elixir  Chartreuse  alb.  ad  |iv  —  M. 
Sig.  3J  *•  i-  d.  in  water. 

91  __  Burmann's  Hypodermic  Solution. 


R.     Conioe  3iij, 

Acidi  acetic,  fort.  3»J5 

Spts.  vini  rect.  3.)  '•> 

Aquae  destil.  ad  §ij.  —  M. 
Sig'  "lv  =  ^j  coniaj.     Begin  witli  one  drop. 


504  FORMULAE. 

92. 
Hypodermic  Injection. 

R.     Daturiae  gr.  j  ; 

Ac.  acetici  fort.  q.  s. ; 

Glycerine  3U  ; 

Aqua?  destil.  ad  ^j. — M. 
Sijj.  Bejnn  with  three  minims. 


93. 

R.    Ammon.  muriat.  3ij  ; 

Pulv.  aromatici,  Jj. — M. 
Divid.  in  chart,  no.  vj. 
Sig.  One  every  hour. 

94. 

R.    Pulv.  paullinas  sorbilis  3j. 

Divid.  in  chart,  no.  xxiv. 

Sig.  One  to  three  every  hour  till  relieved. 

95. 

R.     Fructus  belladonna?  £iv  ; 

Spts.  vini  rect.  ^viij — M. 
Ft.  linimentum. 

The  fresh  berries  should  be  obtained  ;  but,  if  this  is  impossible,  the 
leaves,  either  fresh  or  dried,  in  the  same  quantity  may  be  used.  In  either 
case  the  liniment  should  not  be  used  for  several  days. 

Battery  Fluid  (for  zinc-carbon  batteries). 

R.     Potass,  bichrom.  pulv.  ^viij; 
Aqiue  bullientis  Ov ; 
"When  cold,  add — 
Acidi  sulpli.  ovU- — M« 


INDEX. 


ABSENCE  of  blood  in  cutaneous  vessel 
in  hysteria,  373 
of    "  tendon    reflex"    in    locomotor 

ataxia,  277 

Abstinence  from  food  in  hysteria,  377 
Abuse  of  bromides  in  epilepsy,  329 
Active  cerebral  hyperaemia,  69 
Acute  alcoholism,  351 

cerebral  anaemia,  113 
cerebritis,  149 
myelitis,  233 
softening,  149 
Adult  spinal  paralysis,  247 
JEsthesiometer,  the,  22 

Sieveking's,  22 
Affections   of   the   organs  of    speech    in 

chorea,  394 
Agraphia,  165 

Aitken  on  prognosis  of  softening,  161 
Alalia,  161 
Alcohol  in  urine,  means  of  detecting,  358 

in  ventricular  fluid,  357 
Alcoholism,  351 
acute,  352 
causes  of,  355 
chronic,  354 
definition  of,  351 
dingnosis  of,  359 
hallucination  in,  353 
morbid   anatomy  and   pathology  of, 

356 

prognosis  of,  358 

symptoms  of,  352 

treatment  of,  359 

Anosmia,  cerebral,  113 

spinal,  227 
Anaesthesia,  448 
auditory,  448 
causes  of,  449 

diagnosis  and  prognosis  of,  450 
of  fifth  nerve,  449 
hysterical,  372 
of  radial  nerve,  449 
symptoms  of,  448 
treatment  of,  450 
Aneurism  of  brain,  196 

miliary,  198 

Antero-lateral  amyotrophic  sclerosis,  289 
causes  of,  29'2 
dingnosis  of,  293 
morbid  anatomy  of,  292 
prognosis  of,  293 
symptoms  of,  289 
synonyms  of,  289 
treatment  of,  293 


Antero-epinal  paralysis  of  adults,  247 
causes  of,  252 
definition  of,  247 
diagnosis  of,  252 
morbid    anatomy   and     pa- 
thology of,  252 
prognosis  of,  254 
symptoms  of,  249 
synonyms  of,  247 
treatment  of,  254 
of  infancy,  239 
causes  of,  243 
definition  of,  239 
deformities  in,  239 
diagnosis  of,  246 
electricity  in,  246 
morbid    anatomy   and    pa- 
thology of,  243 
muscular  tissue,  changes  in, 

245 

prognosis  of,  246 
Sinkler's  case  of,  239 
symptoms  of,  239 
synonyms  of,  239 
treatment  of,  246 
Aphasia,  161 

definition  of,  161 
diagnosis  of,  175 
history  of,  162 
infantile,  174 

location  of  speech  centre  in,  168 
Lordat  on,  164 
medico-legal  study  of,  177 
pathology  of,  167 
synonyms  of,  161 
treatment  of,  178 
trephining  in,  179 
with  left  sided  paralysis,  171 
without  lesion,  170 
\poplexy,  83 
Apparatus,  electrical,  30 

for  the  treatment  of  nervous  diseases, 

30 

Van  Bibber's,  30 
Arcus  senilis,  the,  94 
Arrangement  of  nerve-roots  in  posterior 

columns,  285 
Arthropathies   in    cerebral    hemorrhage, 

91 

Asemasia,  161 

Asthenic  cerebral  hypersemia,  69 
Atheromatous  changes  iu  vessels,  97 
Athetosis,  92 

Atrophy,  partial  facial,  266 
causes  of,  268 


506 


INDEX. 


Atrophy,  partial  facial  (continued). 
diagnosis  of,  268 
Draper's  case  of,  267 
pathology  of,  268 
prognosis  of,  268 
synonyms  of,  266 
symptoms  of,  266 
treatment  of,  269 
progressive  muscular,  255 

with  cerebral  sclerosis,  183 
Auditory  vertigo,  124 
causes  of,  126 
definition  of,  124 
diagnosis  of,  128 
pathology  of,  12'>  _ 

synonyms  of,  124 
treatment  of,  128 
Automatic  man,  the,  314 


BASEDOW'S  disease,  412 
Basilar  meningitis,  66 
Bed-sores,  treatment  of,  238 
Bell's  paralysis,  453 
Bloodletting  in  apoplexy,  108 
Blue  line,  the,  475 
Bone  changes  in  posterior  spinal  sclerosis, 

283 

Bony  growths,  198 
Brain  lesions.  97 
tumors,  185 

choked  disk  a  symptom  of,  188 
diagnosis  of,  199 
localization  of,  200 
morbid  anatomy  of,  189 
prognosis  of,  202 
symptoms  of,  185 
treatment  of,  202 
varieties  of,  189 
Brittleness  of  bones  in  locomotor  ataxiii. 

283 

Broca  on  location  of  speech  centre,  168 
Brown-Se'qunrd's  theory  of  auditory  con- 
vulsions, 127 
Bulbar  diseases.  308 
paralysis,  336 

causes  of,  339 

condition  of  tongue  in,  337 

diagnosis  of,  340 

morbid  anatomy  and  pathology 

of,  340 

prognosis  of,  342 
progressive  variety  of,  339 
reflex  variety  of,  339 
stationary  vnriety  of,  339 
symptoms  of,  336 
synonyms  of,  336 
treatment  of,  342 
Burrowes'  experiments,  145 


nAXCEROUS  growths  in  hrain,  190 
\J     Case  of  cerehellar  tremor,  194 
Case  of  hsEmatomn,  42 

of  post-paralytic  chorea,  93 


Case  (continued). 

of  spinal  tumor,  with  persistent  reflex 

sensibility,  215 
Catalepsy,  389 
causes  of,  390 
definition  of,  389 
diagnosis  of,  391 
flexibilitas  cerea  in,  389 
induced  in  animals,  391 
malarial,  390 
morbid   anatomy   and  pathology  of, 

391 

prognosis  of,  392 
symptoms  of,  389 
treatment  of,  392 
Cauteries,  32 
author's,  32 
glass  rod,  32 
fiuerard'p,  33 
Pncquelin's,  33 
Central  neuritis,  91 

spinal  hemorrhage,  220 
Cerebellar  hemorrhage,  112 

tumor,  case  of,  1 94 
Cerebral  anaemia,  113 

causes  of,  116 

chronic,  114 

definition  of,  113 

infantile,  115 

morbid  anatomy  and  pathology 
of,  118 

prognosis  of,  121 

symptoms  of,  114 

synonyms  of,  113 

treatment  of,  121 
congestion,  72 
hemorrhage,  83 

attacks  of,  without  loss  of  con- 
sciousness, 87 

causes  of,  94 

condition  of  eyes  in,  86 

conjugate  deviation  of  eyes  in, 
86 

definition  of,  83 

diagnosis  of,  100 

morbid  anatomy  and  pathology 
of,  96 

post- paralytic  states  in,  91 

prodromata  of,  83 

prognosis  of,  104 

psychical  disturbance  in,  85 

residual  paralysis  in,  88 

respiratory  disturbance  in,  86 

seat  of,  99 

symptoms  of,  83 

time  of  attack  of,  95 

treatment  of,  83 
byperoemia,  69 

causes  of,  73 

definition  of,  69 

diagnosis  of,  78 

influence  of  occupation  in,  73 

local,  79 

morbid  anatomy  of,  77 

pathology  of,  75 


INDEX. 


507 


Cerebral  hyperaemia  (continued). 
prognosis  of,  80 
symptoms  of,  70 
synonyms  of,  69 
treatment  of,  80 
meninges,  diseases  of,  35 
meningitis,  acute,  44 
causes  of,  45 
diagnosis  of,  46 
pathology  and   morbid    an- 
atomy of.  46 
prognosis  of,  49 
symptoms  of,  44 
treatment  of,  49 
chronic,  65 

treatment  of,  68 
pacliymeningitis,  35 

acute,  symptoms  of,  35 
chronic,  causes  of,  39 

morbid  anatomy  and  patho- 
logy of,  39 
osseous  plates  in,  39 
prognosis  of,  39 
(symptoms  of,  37 
treatment  of,  40 
with  haematoma,  40 
case  of,  42 
causes  of,  41 
formation  of  cysts  in,  4t 
morbid    anatomy    and    pa- 
thology of,  41 
prognosis  of,  44 
symptoms  of,  40 
treatment  of,  44 
rheumatism,  51 
sclerosis,  179 

causes  of,  182 
'definition  of,  179 
diffused,  180 
diagnosis  of,  184 
prognosis  of,  184 
symptoms  of,  180 
synonyms  of,  179 
treatment  of,  184 
softening,  148 
acute,  149 

causes  of,  151 
diagnosis  of,  153 
morbid    anatomy   and    pa- 
thology of,  151 
prognosis  of,  153 
symptoms  of,  149 
treatment  of,  153 
chronic,  154 

causes  of,  156 
definition  of,  154 
diagnosis  of,  159 
morbid    anatomy   and    pa- 
thology of,  157 
prognosis  of,  160 
symptoms  of,  154 
treatment  of,  161 
classification  of,  148 
definition  of,  148 
tumors,  Grasset's  classification  of,  190 


Cerebritis,  149 
Cerebro-spinal  diseases,  343 

meningitis,  343 

retraction  of  head  in,  344 
Cerebrum  and  cerebellum,  diseases  of,  69 
Cervical  pachymeningitis,  204 
Cervico-brachial  neuralgia,  427 
Cervico-occipital  neumlgia,  426 
Character   of    the    deposit    in    so-called 

tubercular  meningitis   59 
Charcot  on  reduced  temperature  in  bys- 

tero-epilepsy,  389 
Chloral-bromide   treatment    in    epilepsy, 

333 

Choked  disk,  187 
Chorea,  393 

adult,  398 

among*6chool  children,  400 

case  of,  396 

causes  of,  399 

definition  of,  393 

dependent  upon  tapeworm,  396 

diagnosis  of,  404 

embolic  theory  of,  403 

epidemic,  393 

ether  spray  in  treatment  of,  405 

heart  lesions  of,  401 

malarial,  400 

morbid   anatomy  and  pathology   of, 
401 

of  pregnancy,  397 

post-paralytic,  92 

prognosis  of,  404 

symptoms  of,  393 

synonyms  of,  393 

treatment,  405 

with  eczema,  399 

Chronic   cerebral    pachymeningitis    with 
haematoma,  40 

myelitis,  236 
Clavus  hystericus,  371 
Collateral  circulation,  159 
Condition  of  organs  of  generation  in  hys- 
teria, 370 
Congestion,  cerebral,  70 

spinal,  223 

Congestive  pernicious    fever,  its    resem- 
blance to  cerebro  spinal  meningitis,  345 
Constriction  band,  the,  235 
Contractions,  fibrillary,  256 
Contractures  in  antero-lateral    sclerosis, 
289 

in  hemiplegia,  01 

in  infantile  paralysis,  240 

paralytic,  91 
Contusions    and    punctured    wounds    as 

causes  of  paralysis,  460 
Convulsion  as  a  symptom  of  brain  tumor, 

185 

Convulsive  cerebral  congestion,  71 
Coordination,  284 
Corpuscles,  Gluge's,  157 
Cramp,  dancer's,  484 

telegrapher's,  484 

writer's,  484 


508 


INDEX. 


Cramp  (continued). 
professional.  484 

causes  of,  486 

diagnosis  of,  487 

pathology  of,  486 
"Crises  gastriques,"  281 
Cross  paralysis,  89 
Crum- Brown's  experiments,  124 
Cutaneous  eruptions  in  locomotor  ataxia, 
278 

DA  COSTA  on  cerehrnl  rheumatism,  51 
Decuhitus  paralysis,  46*2 
Delayed  transmission  of  impressions,  236 
Delirium  tremens,  352 
Depraved  appetite  in  hysteria,  372 
Diathetic  growths,  202 
Diplopia,  70 
Diseases  of  cerebral  meninges,  35 

of  cerebrum  and  cerebellum,  69 
Dislocation  as  a  cause  of  paralysis,  461 
Division  of  a  nerve  trunk  as  a  cause  of 

paralysis,  460 
Douleureux,  tic,  420 
Dreams  of  movement,  404 
Duration  of  life  of  hard  drinkers,  358 
Dynamometer,  25 

Mathicu's,  25 

the  author's,  25 

ECHOLALIA,  176 
Eczema  with  chorea,  399 
Education  of  right  side  of  the  brain,  178 
Electrical  apparatus,  30 
Embolic  theory  of  chorea,  403 
Embolism,  129 

of  the  cerebral  vessels,  137 
causes  of,  141 
diagnosis  of,  142 
morbid    anatomy    and    pa- 
thology of,  145 
prognosis  of,  147 
symptoms  of,  138 
treatment  of,  147 
Emprosthotonos,  296 
Endemic  tetanus,  299 
Epidemic  chorea,  393 
Epilepsy,  308 
aborted.  313 

abuse  of  bromides  in,  329 
age  in  causation  of,  316 
auditory,  321 

Brown-S6quard's  experiments  in,  320 
causes  of,  316 

chloral- bromide  treatment  of,  333 
definition  of,  808 
diagnosis  of,  325 
dislocation  of  bones  in,  312 
experimental  production  of,  321 
grave  attacks  of,  309 
heredity  in,  317 
history  of  308 
hystero,  384 

induration  of  cornua  ammonis,  819 
irregular  attacks  of,  313 


Epilepsy  (continued). 
Jackson  on,  322 
light  attacks  of,  312 
masked,  315 
morbid   anatomy  and   pathology  of, 

318 

nocturnal,  311 
prognosis  of,  325 
resembling  hydrophobia,  369 
responsibility  in,  315 
symptoms  of,  309 
synonyms  of,  308 
syphilitic,  325 

temperature  influences  in,  317 
treatment  of,  326 
warnings  in,  309 
Epileptiform  tic,  425 
Equilibrium,  sense  of,  the,  124 
Ergot  in  pachymeningitis,  212 
Eruptions  with  neuralgia,  420 
Essential  paralysis,  239 
Etat  crible,  the,  78 
Examination  of  patient,  17 

post-mortem,  18 
Exhaustion  simulating   acute  tubercular 

meningitis,  64 
Exopthalmic  goitre,  412 
causes  of,  417 
definition  of,  412 
diagnosis  of,  417 
morbid  anatomy  and  pathology 

of,  417 

prognosis  of,  417 
symptoms  of,  412 
synonyms  of,  412 
treatment  of,  418 
unilateral,  414 

Experimental  production  of  epilepsy,  321 
Extravasation  of  blood  in  neuralgia,  421 

FACIAL  neuralgia,  421 
paralysis,  455 

causes  of,  454 
diagnosis  of.  457 
electricity  in,  458 
pathology  of,  456 
prognosis  of,  <I57 
symptoms  of,  453 
synonyms  of,  453 
treatment  of,  458 
wire  hook  in  treatment  of,  458 
spasm  without  pain,  482 
Faradic  apparatus,  31 
Fatty  degeneration  of  muscles,  261 
Fibrillary  contractions,  256 
Flexibilitas  cerea,  389 
Formulae,  490 

Functional  locomotor  ataxia,  281 
spasm,  479 

ri  ALVANIC  batteries,  31 

\T     Gibney    on    traumatic   causation    of 

spinal  irritation,  226 
Glass  rod  cautery,  32 
Gliomala  of  brain,  194 


INDEX. 


509 


Globus  hystericus,  the,  377 

Gluge's  corpuscles,  157 

Goitre,  exopthalmic,  412 

Grasset's  classification  of  brain  tumors, 

190 

Graves'  disease,  412 
Griffin  on  spinal  irritation,  227 

HAMMOND  on  gait  in  lateral  sclerosis, 
294 

Hardening  fluids,  20 
Hemiplegia,  88 

hysterical,  375 
Hemorrhage,  cerebral,  83 

meningeal,  40 

spinal,  218 
Herbert   Major   on  structure  of  insula, 

173 

High  temperature  in  tetanus,  296 
Hints  in  regard  to   methods  of  examina- 
tion and  study,  17 
Holland  on  anal  leeching,  47 
Hydrobromic  acid,  80 
Hydrocephaloid,  113 
Hydrophobia,  361 

causes  of,  366 

curare  in,  369 

diagnosis  of,  368 

Dr.  Hadden's  case  of,  362 

morbid   anatomy   and  pathology  of, 
367 

prognosis  of,  369 

symptoms  of,  361 

synonyms  of,  361 

treatment  of,  369 
Hysteria,  370 

causes  of,  378 

definition  of,  370 

diagnosis  of,  382 

morbid   anatomy  and   pathology  of, 
381 

prognosis  of,  382 

symptoms  of,  370 

treatment  of,  382 
Hysterical  anaesthesia,  372 

arthropathies,  371 

eye  troubles,  373 

hemiplegia,  375 

locomotor  ataxia,  281 

paraplegia,  375 

tremor,  375 
Hystero-epilepsy,  384 

cases  of,  385 

symptoms  of,  385 

INFANTILE  hemiplegia,  174 
JL         paralysis,  239 
Inflammation  of  spinal  cord,  233 
Instruments   used  for    the  diagnosis    of 

nervous  diseases,  22 
Intra-vesical  troubles  in  myelitis,  235 

ACKSON  on  epilepsy,  322 


T  ATERAL  sclerosis  of  the  spinal  cord,  293 
Jj  diagnosis  of,  295 

morbid  anatomy  of,  294 
symptoms  of,  293 
synonyms  of,  293 
treatment  of,  2i>5 
Lead  poisoning,  470 

causes  of,  472 

diagnosis  of,  475 

from  tea  drinking,  474 

morbid  anatomy  and  pathology 

of,  475 

prognosis  of,  476 
synonyms  of,  470 
treatment  of,  476 
Local  paralysis,  453 
Localization  of  tumors,  200 
Locomotor  ataxia,  267 
hysterical,  281 
spurious,  281 
Loring's  experiments,  78 
Lyssaphobia,  361 

MALE  hysteria,  378 
Mastodynia,  431 
Mdniere's  disease,  124 
Meningeal  hemorrhage,  219 
Meningitis,  acute  and  chronic  spinal,  204 

symptoms  of,  204 
granular,  52 
cerebro-spinal,  343 
causes  of,  344 
definition  of,  343 
diagnosis  of,  345 
morbid  anatomy  and  pathology 

of,  345 

prognosis  of,  346 
symptoms  of,  343 
synonyms  of,  343 
treatment  of,  346 
chronic  cerebral,  65 
causes  of,  68 
diagnosis  of,  68 
morbid    anatomy    and    pa- 
thology of,  68 
prognosis  of,  h8 
symptoms  of,  65 
treatment  of,  68 

connected  with  cardiac  disease,  51 
of  the  aged,  52 
rheumatic,  50 
senile,  52 

tubercular  (granular),  52 
basal,  53 
causes  of,  58 
development  of,  62 
diagnosis  of,  53 
morbid  anatomy  and  pathology 

of,  59 

prognosis  of,  62 
symptoms  of,  53 
treatment  of,  64 
tubercular  deposits  in,  61 
vertical,  53 
vital  signs  in,  55 


510 


INDEX. 


Meningo-cerebritis,  149 

Mental  changes  in  looomotor  ataxia,  279 

Migraine,  4*21 

Miliary  aneurisms,  98 

Mimetic  chorea,  400 

Morbid  impulses  in  hysteria,  372 

Mortality  in  tubercular  meningitis,  58 

Mottled     skin     in     pseudo-bypertrophic 

paralysis,  273 
Multiple  embolism,  139 
Myelitis,  236 

causes  of,  236 

cbronic,  236 

diagnosis  of,  237 

morbid   anatomy  and   pathology  of, 
237 

symptoms  of,  236 

treatment  of,  238 

troubles  in,  235 


NERVES,  tumors  of,  451 
Neuralgia,  age  and  sex  in  causation 

of,  434 

association  with  epilepsy,  432 
bad  teeth  as  a  cause  of,  434 
causes  of,  432 
cervico-occipital,  426 
circulatory  disturbances  in,  420 
clavus,  423 

coarse  nnd  fine  varieties  of,  439 
connection  with  pulmonary  disease, 

432 

crural,  4 
definition  of,  419 
diagnosis  of,  436 
electricity  in  treatment  of,  442 
excision  of  supra-orbital  in,  424 
facial,  421 

influence  of  temperature  in,  435 
intercostal,  428 
inveterate  case  of,  an,  437 
morbid  anatomy  of,  436 
nerve  areas  in,  441 
uerve  section  in,  432 
of  testis,  424 
ovarian,  431 
pain  of,  419 
prognosis  of,  436 
renal,  431 
sciatic,  428 
syphilitic,  422 
treatment  of,  438 
trigcminal,  421 
trophic  disturbances  in,  420 
urethra),  431 
visceral,  430 
Neuritis,  444 

causes  of,  446 

morbid   anatomy  and    pathology  of, 

446 
nerve  section  in,  447 

stretching  in,  447 
prognosis  of,  447 
symptoms  of,  444 
treatment  of,  447 


Neuritis  (continued). 

trophic  changes  in,  445 
Neuromata,  sarcomatous,  402 

treatment  of,  452 
Nystagmus,  189 

OCCLUSION  of  intracranial  vessels,  129 
Occupation,  and  its  relation  to  cere- 
bral hyperaemia,  73 
Oculnr  trouble  with  brain  tumor,  187 
Ophthalmoscope,  the,  28 
Opisthotonos,  296 

Organs  of  speech,  affection  of  in  chorea, 
394 

DACHYMENINGITIS  as  a  result  of  in- 
1.         jury,  35 

spinal,  causes  of,  207 

diagnosis  of,  211 

morbid  anatomy  and  pathology 
of,  208 

prognosis  of,  210 

symptoms  of,  206 

treatment  of,  211 
Painters'  colic,  470 
Palsy,  Scrivener's,  486 
shaking,  406 
wasting,  255 

Paralysis,  adult  spinal,  247 
after  dislocation,  461 
agitans,  406 

case  of,  408 

causes  of,  408 

diagnosis  of,  410 

morbid  anatontfj^nind   pathology 
of,  409 

prognosis  of,  411 

symptoms  of,  407 

synonyms  of,  406 

treatment  of,  411 
nntero-spinal,  of  infancy,  239 
bulbar,  336 
cross,  89 

Cruveilhier's,  256 
diphtheritic,  466 

case  of,  467 

causes  of,  468 

diagnosis  of,  469 

morbid  anatomy  and   pathology 
of,  468 

prognosis  of,  469 

symptoms  of,  467 

treatment  of,  4(i9 
facial,  453 

from  pressure  of  forceps,  462 
heat  in  the  treatment  of,  111 
hysterical,  375 
local,  453 

of  cranial  nerves,  277 
of  sphincters,  235 
pseudo-hypertrophic,  269 
residual,  88 
temporary  spinal,  251 
traumatic,  453 
Paralytic  chorea,  395 


INDEX.  ' 


511 


Paraplegia,  234 

hysterical,  375 
Parkinson's  disease,  406 
Partial  cerebral  anaemia,  113 
Passive  cerebral  hyperaemia,  69 
Pathology  of  spasm,  483 
Perivascular  spaces,  the,  75 
Petrina  on  localization,  200 
Piesmeter,  the,  26 
Pleurodynia,  428 
Pleurosthotonos,  296 
Poisoning,  lead,  470 
Posterior  spinal  sclerosis,  276 

ascending   and  descending, 
277 

bladder  complication  in,  277 

causes  of,  281 

diagnosis  of,  286 

morbid    anatomy    and    pa- 
thology of,  282 

neuralgia  in,  276 

prognosis  of,  287 

state  of  mind  in,  277 

symptoms  of,  276 

synonyms  of,  276 

treatment  of,  287 

Post-hemiplegic  disorders  of  movement,  92 
Post-paralytic  chorea,  92 
Primary  and    compensatory  contractions 

in  paralysis,  240 

Prodromata  of  infantile  palsy,  239 
Professional  cramp,  484 

muscular  atrophy,  486 
Progressive  muscular  atrophy,  255 

causes  of,  268 

definition  of,  255 

diagnosis  of,  363 

history  of,  255 

morb'nl    anatomy    and    pa- 
thology of,  259 

prognosis  of,  265 

resembling  lead  palsy,  263 

symptoms  of,  255 

synonyms  of,  255 

treatment  of,  255 

Pseudo-hypertrophic  muscular  paralysis, 
269 

cases  of,  271 

causes  of,  273 

diagnosis  of,  275 

heredity  in,  273 

lordosis  in,  272 

pathology  and    morbid   an- 
atomy of,  274 

prognosis  of,  275 

symptoms  of,  269 

synonyms  of,  269 

treatment  of,  275 
Puerperal  embolism,  142 
hysteria,  379 

RABIES  canina,  361 
Reflex  spasm,  481 

Retraction    of    head    in     cerebro-spinal 
meningitis,  344 


Rigor,  35 

Risus  sardonicus,  295 
Rombergon  delayed  transmission  of  pain- 
ful impressions,  236 
Rubber  muscle,  the,  32 

SCIATICA,  428 
Sclerosis,  antero-lateral,  289 
cerebral,  179 
cerebro-spinal,  343 
causes  of,  350 
diagnosis  of,  351 
morbid  anatomy  and  pathology 

of,  350 

prognosis  of,  851 
resembling  paralysis agitans,  351 
stages  of,  346 
symptoms  of,  346 
synonyms  of,  346 
treatment  of,  351 
lateral,  293 
posterior-spinal,  276 
Scle"rose  en  plaques,  346 
Scrivener's  palsy,  486 
Seat  of  cerebral  hemorrhage,  99 
Senile  meningitis,  52 
Seventh  nerve,  paralysis  of,  457 
Shaking  palsy,  406 
Sieveking's  oesthe.siometer,  22 
Simple  apoplexy,  83 
Sleep    not    necessarily   due    to    cerebral 

anaemia,  120 

Softening  after  vascular  plugging,  134 
cerebral,  148 

not  necessarily  an  inflammatory  pro- 
cess, 148 

of  posterior  columns  in  tetanus,  303 
Spaces,  the  perivascular,  75 
Spasm,  facial,  without  pain,  482 
from  genital  irritation,  481 
functional,  479 

with  voluntary  movements,  480 
pathology  of,  483 
reflex,  481 
treatment  of,  483 
Spinal  anaemia,  so-called,  227 

Gribney  on    traumatic  causation 

of,  226 

Griffin  on,  227  . 
congestion,  223 

symptoms  of,  223 
hemorrhage,  218 
causes  of,  219 
diagnosis  of,  221 
morbid  anatomy  and   pathology 

of,  220 

prognosis  of,  221 
symptoms  of,  219 
synonyms,  218 
treatment  of,  222 
hypersemia,  subacute,  224 
causes  of,  224 
diagnosis  of,  226 
morbid  anatomy  and  patho- 
logy of,  225 


512 


INDEX. 


Spinal  hypersemia,  snbacute  (continued). 
prognosis  of,  226 
symptoms  of,  224 
treatment  of,  226 
irritation,  227 

causes  of,  229 

diagnosis  of,  231 

morbid  anatomy  and  pathology 

of,  230 

prognosis  of,  231 
symptoms  of,  227 
treatment  of,  231 
meninges,  diseases  of,  204 
meningitis,  acute  and  chronic,  204 
pachymeningitis,  206 
causes  of,  207 
symptoms  of,  206 
paralysis,  temporary,  251 
tumor,  213 

causes  of,  217 

diagnosis  of,  218 

morbid  anatomy  and  pathology 

of,  218 

prognosis  of,  218 
symptoms  of,  213 
treatment  of,  218 
varieties  of,  213 
Spurious  locomotor  ataxia,  281 
Staining  solutions,  21 
Sthenic  cerebral  hyperseraia,  69 
Stomachic  vertigo,  123 
St.  Vitus'  dance,  393 
Syncope,  113 
Syphilis  of  the  brain,  192 
Syphilitic  epilepsy,  325 
pachymeningitis,  37 

rTABES  dorsalis,  276 

1      Tin-lie  carebrale,  56 

Tarantism,  393 

Temporary  spinal  paralysis,  251 

Tetanus,  303 

allied  to  strychnia  poisoning,  303 

causes  of,  298 

curare  in,  S07 

definition  of,  295 

diagnosis  of,  305 

endemic,  299 

morbid   anatomy  and   pathology  of, 
302 

nascentium,  297 

pleurosthotonos  in,  296 

prognosis  of,  305 

risus  sardonicus  in,  295 

softening  of  posterior  column  in,  303 

statistics,  305 


Tetanus  (continued). 
symptoms  of,  295 
synonyms  of,  295 
treatment  of,  306 
urine  in,  297 
Tetany,  480 
The  epileptic  zone,  322 
Theory  of  sleep,  120 
Thermometer,  the,  22 
Thrombosis,  129 

of  cerebral  arteries,  129 
case  of,  130 
causes  of,  133 
diagnosis  of,  135 
morbid    anatomy   and    pa- 
thology of,  133 
treatment  of,  135 
of  sinuses  and  veins,  135 

after  aural  disease,  1 35 
Tic  douleureux,  420 

epileptiform,  425 
Torticollis,  483 
Traumatic  paralysis,  463 
diagnosis  of,  463 
prognosis  of,  463 
treatment  of,  464 
Treatment  of  bed-sores,  238 

of  spasm,  483 
Tremor,  409 

functional,  410 
Trismus  nascentium,  297 
Trophic  changes  in  traumatic  paralysis, 

460 

Tubercular  deposit  in  motor  centre,  61 
Tumors  of  brain,  185 
of  nerves,  451 
spinal,  213 

TTNILATERAL  tremor  as  a  result  of 
U     localized  meningitis,  46 
Unreliability  of  post-mortem  appearances 

in  hydrophobia,  867 
Urine  in  tetanus,  297 

VARIATIONS  of  temperature  in  cere- 
bral hemorrhage,  86 
Vertigo,  123 

WrIRE    hook    in    treatment    of    facial 
paralysis,  458 
Writers'  cramp,  484 

r/ ONE,  the  epileptic,  321 


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annum).  j    in  advance. 

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Dollars  and  a  Half. 

In  commencing  a  new  half  century  in  the  career  of  the  "AMERICAN  JOURNAL  OF  THE 
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of  usefulness.  Sustained  as  it  is  by  the  profession  of  the  whole  United  States,  and 
with  a  circulation  extending  to  every  country  in  which  the  English  language  is  read, 
the  efforts  of  the  editors  will  be  directed,  as  heretofore,  to  render  it  in  every  way 
worthy  of  its  reputation,  and  of  the  universal  favor  with  which  it  is  received.  With 
its  attendant  periodicals,  the  "MKDICAL  NEWS  AND  LIBRARY''  and  the  "MONTHLY  AB- 
STRACT OF  MEDICAL  SCIENCE,"  it  combines  the  advantages  of  the  elaborate  preparation 
which  can  be  given  to  a  quarterly,  and  the  prompt  conveyance  of  intelligence  by  the 
monthly,  while  the  whole,  being  under  a  single  editorial  supervision,  the  subscriber 
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These  efforts  the  publisher  seeks  to  second  by  offering  these  periodicals  at  a  price 
unprecedentedly  low  —  a  price  which  places  them  within  the  reach  of  every  practitioner, 
arid  gives  the  equivalent  of  three  large  octavo  volumes  for  the  comparatively  trifling 

("For  THE  OBSTKTRICAL,  JOURNAL,"  see  p.  23  ) 


2  HENRY  C.  LEX'S  PUBLICATIONS — (Am.  Journ.  Med.  Sciences). 

cost  of  Six  DOLLARS  per  annum. 

The  three  periodicals  thus  offered  are  universally  known  for  their  high  professional 
fttaudiug  in  their  several  spheres. 

THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES, 

EDITKDBT  ISAAC  HAYS,  M.D.,  AITD  I.  MINIS  HAYS,  M.D., 

is  published  Quarterly,  on  the  first  of  January.  April.  July,  and  October.  Each  num- 
ber contains  nearly  three  hundred  larpe  octavo  pages,  appropriately  illustrated  wher- 
ever necessary.  It  has  now  been  issued  regularly  tor  over  FIKTY  years,  during  the 
whole  of  which  time  it  has  been  under  the  control  of  the  present  senior  editor.  Through- 
oat  this  long  period,  it  ha*  maintained  its  position  in  the  highest  rank  of  medical  peri- 
odicals both  at  home  and  abroad,  and  has  received  the  cordial  support  of  the  entire 
profession  in  this  country.  Among  its  Collaborators  will  be  found  a  large  cumber  of 
the  most  distinguished  names  of  the  profession  in  every  section  of  the  United  States, 
rendering  its  original  department  a  truly  national  exponent  of  American  medicine.* 

Following  this  is  the  ''RgriRW  DRPARTMBNT,"  containing  extended  and  impartial 
reviews  of  important  new  works,  together  with  numerous  elaborate  "ANALYTICAL  AND 
BIBLIOGRAPHICAL  NOTIOKS"  giving  a  complete  survey  of  medical  literature.. 

This  is  followed  by  the  "QUARTERLY  SUMMARY  OF  IMPROVEMENTS  AND  DISCOTKRIE? 
IN  THE  MEDICAL  SCIENCES,"  classified  and  arranged  under  different  heads,  presenting 
a  very  complete  digest  of  medical  progress  abroad  as  well  as  at  home. 

Thus,  during  the  year  1877,  the  "JOURNAL"  furnished  to  its  subscribers  101  Original 
Communications,  1H5  Reviews  and  Bibliographical  Notices,  and  227  articles  in  the 
Quarterly  Summaries,  making  a  total  of  FOUR  HTNDKED  AND  SIXTY-THKER  articles 
illustrated  with  64  maps  and  wood  engravings,  emanating  from  the  best  professional 
minds  in  America  and  Europe. 

That  the  efforts  thus  made  to  maintain  the  high  reputation  of  the  "JOURNAL"  are 
fuccessful,  is  shown  by  the  position  accorded  to  it  in  both  America  and  Europe  as  a 
leading  organ  of  medical  progress : — 

This  i*  universally  acknowledged  as  tbe  leading!  The  Philadelphia  Medical  and  Physical  Journal 
American  Journal,  H  ml  has  been  conducted  by  Or  !  issued  its  first  number  in  1S20,  and  after  a  brilliant 
Hays  alone  until  I860,  when  his  son  was  associated  'career,  was  succeeded  in  1>;7  by  the  American 
with  him.  We  quite  agree  with  tbe  critic,  that  this  'Journal  of  tbe  Medical  Sciences,  a  periodical  of 
journal  is  second  to  none  in  the  language,  and  cheer-  world-wide  reputation;  the  ablest  and  »u<-  of  the 
fully  accord  toil  tbe  first  place,  for  uowhere  shall  !  oldest  periodicals  in  the  world — a  journal  which  baa 


we  find  more  able  and  more  impartial  criticism,  and 
nowhere  such  a  rep-rtory  of  able  original  articles 
Indeed,  now  that  the  "British  and  Foreign  Medic><- 
Chirnrgical  Review"  ban  terminated  it»  career,  the 
American  Journal  Maud*  without  a  rival. — London 
M«d.  Times  and  Gazette,  Mov.  24,  1877. 

The  present  number  of  the  American  Journal  Is  an 
exceedingly  good  on«.  and  gives  every  promise  of 
maintaining  the  well-earned  repntali»n<  f  the  re  view 
Our  venerable  contemporary  bag  our  best  wishes, 
and  we  can  only  expre-s  the  hope  that  it  may  con- 
tinue its  work  with  as  much  vigor  and  excellence  for 
the  next  flf  y  years  ax  it  has  exhibited  in  the  past. 


an  nnsullied  record. — Ctrosa'y  Uiatury  of  A.mtricu.n 
Jft-d.  LUf.ratv.rf.,  187«. 

It  is  universally  acknowledged  to  be  tbe  leading 
American  medical  journal,  and,  iu  oar  opinion,  is 
second  to  none  in  tne  language  —  Bosttn  Med.  nmi 
Stirg.  Journal,  Oct.  1^77 

This  is  the  medical  journal  of  onr  country  to  which 
the  American  physician  abroad  will  point  witli  tlin 
greatest  sati  faction,  as  reflecting  the  state  of  iiiedivaj 
culture  iu  bis  country.  For  a  great  mauy  years  it 
hat  been  the  medium  tlirongh  which  onr  ablest  writ- 
ers have  made  kuowu  their  <liscover'i«>8  and  observa- 
tions —AMrf.es  of  L.  P  Yrrn'teU.  M.D.,  before  Inter- 


— London  Lnnctt,  Nov.  24,  1877.  i  national  Mtd.  Congrut,  fcept.  1670. 

And  that  it  was  specifically  included  in  the  award  of  a  medal  of  merit  to  the  Publisher 
in  the  Vienna  Exhibition  in  1873. 

The  subscription  price  of  the  ••  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES"  has 
never  been  raised  during  its  long  career.  It  is  still  FIVE  DOLLARS  per  annum  ;  and 
when  paid  for  in  advance,  the  subscriber  receives  in  addition  tbe  "  MEDICAL  NKWS  AM> 
LIBRARY,"  making  in  all  about  1500  large  octavo  pages  per  annum,  free  of  postage. 

II. 

THE  MEDICAL  NEWS  AND  LIBRAKY 

is  a  monthly  periodical  of  Thirty-two  large  octavo  pages,  making  384  pages  per 
annum.  Its  '-LIBRARY  DEPARTMENT"  is  devoted  to  publishing  standard  works  on  the 
various  branches  of  medical  science,  paged  separately,  so  that  they  can  be  detached 
for  binding,  when  complete.  In  this  manner  subscribers  have  received,  without  ex- 
pense, such  works  as  ••  WATSON'B  PRACTICE,"  "WEST  ON  CHILDREN."  "MALOAKJNE'S 
SUROKRY,"  "STOKKS  ON  FEVER,"  and  many  other  volumes  of  the  highest  reputation 
and  usefulness.  GOSSELIN'S  "  CLINICAL  LECTURES  ON  SUROERY,"  having  been  com- 
pleted in  the  number  for  June,  1878,  with  July  will  be  commenced  the  publication  of 
-LECTURES  ON  THK  D  SBASES  OK  THE  NERVOUS  SXSTBM,"  by  J.  M.  CHARCOT,  Professor 
to  the  Faculty  of  Medicine  of  Paris,  translated  from  the  French  by  (J.EOROB  SIGERSON. 


*  Communications  are  invited  from  gentlemen  in  all  parts  of  the  country.     Elaborate  articles  inserted 
by  the  EJU»r  are  paid  for  by  tbe  Publisher. 


( HENRY  C.  LEA'S  PUBLICATIONS— (/1m.  Journ.  .Med.  Sciences).         3 

M  D..  M.Ch.,  Lecturer  on  Biolopy,  etc.,  Catholic  Univ.  of  I  relate]   (see  p   16)  thus 
rendering  this  date  a  valuable  and  convenient  time  to  comnn  nee  subscriptions 

Ihe  "NKWs  DEPARTMENT"  of  the  "MEDICAL  NEWS  AND  LIBRARY"  presents  the 
current  information  of  the  month,  with  Clinical  Lectures  and  Hospital  Gleaning 
A  new  and  attractive  feature  of  this  will  be  found  in  an  I'laborate  series  of  ORIOINAL 
AMERICAN  CLINICAL  LKCTURKS,  specially  contributed  to  the  News  by  gentlemen  of 
ihe  highest  reputation  in  the  profession  throughout  the  United  States.  The  amuse- 
ments for  this  are  not  as  yet  completed,  but  already  the  co-operation  bus  be~en 
secured  of  the  following: — 

S.  1).  GROSS.  M.D  ,  Prof,  of  Surgery.  Jefferson  Med   Coll  .  Philada. 


ROBERTS  BAKTHOLOW.  M.D..  Prof.  Theory  and  Practice  of  Med..  M  ;d.  Coll.  of  Ohio 

T.  G.  RICHARDSON,  M  IX.  Prof.  Genl.  arid  Clin.  Surg.,  Univ.  of  La.,  New  Orleans 

WILLIAM  GOODEI.L.  M.D..  Prof.  Clin.  Gyncecolosy,  Univ.  of  Penna. 

FORDYCK  BARKKR.  M.I)..  Prof.  Clin.  Midwiiery,  Ac..  Bellevue  Hosp.  Med.  Coll    NY 

N.  S.  DAVIS,  M.D.,  Prof.  Prin   and  Prac.  of  Med..  Chicago  Med.  Coll. 

L.  A.  DCHRI.VO.  M.D..  Clia.  Prof,  of  Diseases  of  the  Skin,  Univ.  of  Penna. 


J.  P.  WHITE,  M.  D..  Prof,  of  Obstetrics.  £c.,  Univ.  of  Buffalo. 

JOHN  ASHHURST.  Jr.,  M  D  ,  Prof,  of  Clin.  Surg..  Univ.  of  Penna. 

D.  WARREN  BRICKKLL.  M.D..  Prof.  Obstetrics.  £c.,  Charity  Hosp.  Med  Coll.   N.  0 

WILLIAM  PKPPKR.  M.D..  Prof.  Clin.  Medicine.  Univ.  of  Penna. 

J.  LEWIS  SMITH,  M..D.,  Cliu.  Lee.  on  Die.  of  Chil.,  Bellevue  Hosp  Med.  Coll.,  N.  Y. 

WILLIAM  F.  NORKIS.  Ml).,  Clin.  Prof,  of  Diseases  of  the  Kye.  Univ.  of  Penna. 

P.  S.  CONNER.  M.D..  Prof,  of  Anat.  and  Clin.  Surgery,  Med.  Coll.  of  Ohio,  Uin. 

THOMAS  G.  MORTOX.  M.  I).,  Surgeon  to  Penna.  Hospital,  Philad.i. 

F.  J.  BUMSTKAD.  MD..  late  Prof,  of  Venereal  Dia.,  Coll.  Phys.  and  Surg.,  N.  Y. 

J.  Fl.  HUTCHINSOX,  M  D.,  Physician  to  Penna.  Hospital. 

F.  PKYRK  PORCH  ER,  M.D  .  Prof  of  Mat.  Med.  and  Cliu.  Medicine,  Med.  Coll.  of  S.C. 

CHRISTOPHER  JOHNSON.  M.D.,  Prof,  of  Surgery,  Univ.  of  MJ.,  Baltimore. 

S.  W.  GROSS.  M.D..  rinrg.  to  Philada.  Hospital. 

WILLIAM  THOMSON,  M  D.,  Lecturer  on  Ophthalmology,  Jeff.  Med.  Coll.,  Philada. 

With  contributors  such  as  these,  representing  every  portion  of  the  United  States 
the  publisher  feels  safe  in  promising  to  the  subscriber  a  series  of  practical  lectures 
unsurpassed  in  variety,  interest,  and  value. 

As  stated  above,  the  subscription  .>rice  of  the  "MKDICAL  NEWS  AND  LIBRARY"  is 
ONE  DOLLAR  per  annum  in  advance;  and  it  is  furnished  without  charge  to  all  advance- 
paying  subscribers  to  the  "AMERICAN  JOURNAL  OF  THE  MEDICAL  .SOIKXCKS." 

III. 

THE  MONTHLY  ABSTRACT  OF  MEDICAL  SCIKNCE 

is  issued  on  the  first  of  every  month,  each  number  containing  forty-eight  large  octavo 
pages,  thus  furnishing  in  the  course  of  the  year  about  six  hundred  pages.  The  aim 
of  the  •'  ABSTRACT"  is  to  present—  without,  duplicating  the  matter  in  the  "  JOURNAL" 
and  '•  NEWS"  —  a  careful  condensation  of  all  that  is  new  and  important  in  the  medical 
journalism  of  the  world,  and  all  the  prominent  professional  periodicals  of  both  hemi- 
spheres are  at  the  disposal  of  the  Editors.  To  show  the  manner  in  which  this  plan 
has  been  carried  out  it  is  sufficient  to  state  that  during  the  year  1877  it  contained  — 

.•??  Art'n-lcs  mi  An"tnmff  <*»'(  P/»//v»o/oj7//. 

X?          "  •<     Mut'-i-iti  Maiicti  <unl   Therapeutics. 


tif)         '  "     Mi<lifif--rji  <m  'I  Giini 

0          "          "     2Hf<lifitl  Jni-iain-iid.CH.ci:  ami,  Tuxicoloyi/  — 

making  in  all  527  articles  in  a  single  year. 

The  subscription  to  the  "  MONTHLY  ABSTRACT,!'  free  of  postage,  is  Two  DOLLARS 
AND  A  HALF  a  year,  in  advance. 

As  stated  above,  however,  it  will  be  supplied  in  conjunction  with  the  "AMERICAN 
JOURNAL  OF  THE  MEDICAL  SCIENCES"  and  the  "MEDICAL  NEWS  AND  LIBRARY,"  making 
in  all  about  TWKNTY-ONB  HUNDRED  pages  per  annum,  the  whole  free  uf  postage,  for 
Six  DOLLARS  a  year,  in  advance. 

In  this  effort  to  bring  so  large  an  amount  of  practical  information  within  the  reach 
of  every  member  of  the  profession,  the  publisher  confidently  anticipates  the  friendly 


4  HENRY  C.  LEA'S  PUBLICATIONS — (Dictionaries). 

aid  of  all  who  ore  interested  in  the  dissemination  of  sound  medical  literature.  ,  Hi- 
trusts,  especially,  that  the  subscribers  to  the  "AMKKICAN  MKDICAL  JOURNAL"  will  call 
the  attention  of  their  acquaintances  to  the  advantages  thus  offered,  and  that  lie  will 
be  sustainril  in  the  endeavor  to  permanently  establish  medical  periodical  literature 
on  a  footing:  of  cheapness  never  heretofore  attempted. 

PREMIUM  FOE  OBTAINING  NEW  SUBSCRIBERS  TO  THE  "JOURNAL." 

Any  gentleman  who  will  remit  the  amount  for  two  subscriptions  for  1878,  one  of 
which  must  he  for  a  nnv  subscriber,  will  receive  as  a  PRKMIUM,  (reel)}'  mail,  a  copy  of 
"  BROWNE  ON  THK  USB  OF  THK  OPHTHAKMOSOOPK"  (for  advertisement  of  which  see  p. 
2'.'),  or  of  "Fox  os  SKIN  DISKASKS"  (see  p.  20),  or  of  "  FLINT'S  ESSAYS  <>.v  CONSKRVA- 
TITE  MEIMCINR"  (see  p.  15),  or  of  "STUROKS'S  CUMOAI.  MKDICINK"  (see  p.  14),  or  of 
the  new  edition  of  "SWAYNK'S  OBSTKTRIC  APHORISMS"  (see  p.  22).  or  of  "TANNKR'S 
CLINICAL  MANUAL"  (see  p.  5),  or  of  "CMAMBKRS'S  RESTORATIVK  MRDICINK"  (see  p. 
18),  or  of  "\VEST  ON  NERVOUS  DISORDERS  OF  CHILDREN''  (see  p.  21). 

*  *  (jientlemen  desiring  to  avail  themselves  of  the  advantages  thus  offered  will  do 
well  to  forward  their  subscriptions  at  an  early  day,  in  order  to  insure  the  receipt  of 
complete  sets  for  the  year  1878. 

^g"  The  safest  mode  of  remittance  is  by  bank  check  or  postal  money  order,  drawn 
to  the  order  of  the  undersigned.  Where  these  are  not  accessible,  remittanves  for  the 
"JOURNAL"  may  be  made  at  the  risk  of  the  publisher,  by  forwarding  in  RKOISTKKKD 
letters.  Address, 

1I1.NRY  C.  LEA,  Nos.  706  and  708  SANSOM  ST.,  PHILADELPHIA,  PA. 

riUNOLISON  (ROBLEY),  M.D., 

"^  Late  Professor  of  Ingt  itutts  of  Medicine  in  Jefferson  Medical  College,  Philadelphia. 

MEDICAL  LEXICON;  A  DICTIONARY  OF  MEDICAL  SCIENCE:  Con- 
taining a  concise  explanation  of  the  various  Subject?  and  Terms  of  Anatomy,  Physioloj  y. 
Pathology,  Hygiene,  Therapeutics.  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medic  n I 
Jurisprudence,  and  Dentistry.  Notices  of  Climate  and  of  Mineral  Waters;  Formulae  f<  T 
Officinal,  Empirical,  and  Dietetic  Preparations  ;  with  the  Accentuation  and  Etymology  c  f 
the  Terms,  and  the  French  and  other  Synonymes ;  so  as  to  constitute  a  French  as  well  as 
English  Medical  Lexicon.  A  New  Edition.  Thoroughly  Revised,  and  very  greatly  Mod- 
ified and  Augmented.  By  RICHARD  J.  I'UNGLISON,  M.D.  In  one  very  large  and  hand- 
some  royal  octavo  volume  of  over  1100  pages.  Cloth,  $6  50;  leather,  raised  bands,  $7  50. 
(Just  Issued.) 

The  ohject  of  the  author  from  the  outset  has  not  been  to  make  the  work  a  mere  lexicon  or 
dictionary  of  terms,  but  to  afford,  under  each,  a  condensed  view  of  its  various  medical  relations, 
and  thus  to  render  the  work  an  epitome  of  the  existing  condition  of  medical  science.  Starting 
with  this  view,  the  immense  demand  which  has  existed  for  the  work  has  enabled  him,  in  repeated 
revisions,  to  augment  its  completeness  and  usefulness,  until  at  length  it  has  attained  the  position 
of  a  recognized  and  standard  authority  wherever  the  language  is  spoken. 

Special  pains  have  been  taken  in  the  preparation  of  the  present  edition  to  maintain  this  en 
viablereputntion.  Puringthe  t»  n  years  which  have  elapsed  since  the  last  revision,  the  additior  s 
to  the  nomenclature  of  the  medical  sciences  have  been  greater  than  perhaps  in  any  similar  period 
of  the  past,  nnd  up  to  the  time  of  his  death  the  author  labored  assiduously  to  incorporate  every- 
thing requiring  the  attention  of  the  student  or  practitioner.  Since  then,  the  editor  has  been 
equally  industrious,  so  that  the  additions  to  the  vocabulary  are  more  numerous  than  in  any  pre- 
vious revision.  Especial  attention  hap  been  bestowed  on  the  accentuation,  which  will  be  found 
marked  on  every  word.  The  typ -graphical  arrangement  has  been  much  improved,  rendering 
reference  much  more  easy,  nnd  evsry  care  hns  been  taken  with  the  mechanical  execution.  The 
work  has  been  printed  on  new  type,  small  but  exceedingly  clear,  with  an  enlarged  pnge,  so  that 
lie  additions  have  been  incorporated  with  an  increase  of  but  little  over  a  hundred  pages,  and 
the  volume  now  contains  the  matter  of  at  least  four  ordinary  octavos. 

A  book  well  known  to  our  reader*,  and  of  which  .j  Cory  of  technical  terms  is  simply  a  rinf  qua  non.  In  a 
every  American  ought  to  lit- proud.  A'heu  thu  learned  .i-icnre  HO  extensive,  and  with  such  collaterals  H*  nirdi- 
author  of  the  work  pact-oil  nway.  probably  all  of  us  line,  It  is  as  much  n  necessity  also  to  the  practising 
feared  lest  th«  honk  should  n<  t  maintain  its  place  physician.  To  meet  the  wants  of  students  and  most 
in  the  advancing  science  wlm«e  terms  it  defines.  Knr-  physicians,  the  dictionary  rnufct  be  condensed  while 


tunately,  Dr.  Kichnrd  J.  Dunirlison.  having  assisted  hie 
futher  in  the  revision  of  several  editions  of  the  work, 
and  having  been,  therefore,  trnined  in  the  met  hods  and 


•omprehensive,  and  practical  while  perspicacious.  Jt 
*ras  because  Dunglison's  met  these  indications  that  it 
became  at  once  the  dictionary  of  general  use  wherever 


imbued  with  the  spirit  of  the  book,  has  been  able  to     medicine  was  studied  in  the  Knclish  language.     In 
edit  it.  not  in  the  patchwork  manner  so  dear  to  the  I  former  revision  have  the  alterations  and  additions 


heart  of  book  editors,  so  repulsive  to  the  taste  of  intel- 
ligent book  readers,  but  to  edit  it  us  a  work,  of  the  kind 
should  be  edited — to  carry  it  on  steadily,  without  jar 
or  interruption,  along  the  grooves  of  thought  it  has 
travelled  during  its  lire!inie.  To  show  the  magnitude 
of  the  task  which  Dr  Dunuli^on  has  acstimed  and  car- 
ried throiiL-h.it  is  only  necessary  to  t-taie  that  more 


great.  More  than  six  thousand  new  subjects  and  terms 
nave  been  added.  The  chief  terms  have  been  set  in  black 
'etter,  while  the  derivatives  follow  in  small  caps;  an 
arrangement  whicb  greatly  facilitates  reference.  We 
may  safely  confirm  the  hope  ventured  by  the  editor 
"  that  tlie  work,  which  possesses  for  him  a  filial  as  well 
'  an  Individual  interest,  will  be  found  worthy  a  con- 


than  six  thousand  new  subjects  have  been  added  in  the  |  'immure  of  the  position  so  long  accorded   to   it  as  a 
present  edition.— I'/nla.  Mrit.  Tinitt,  Jan.  3,  1874.  "tandard  authoritv."—  CHncintmti  Clinic,  Jan.  10,  1874. 

About  the  first  book  purchased  by  the  medical  stu  '      It  has  the  rare  merit  that  it  certainly  has  no  ri»  al 
dent  is  the  Medical  Dictionary.    The  lexicon  explana-    in  the  English  language  for  accuracy  and  extent  «.-i' 

1  references. — London  Medical  Gatette. 


HENRY  C.  LEA'S  PUBLICATIONS — (Manuals). 


A  CENTURY  OF  AMERICAN  MEDICIXE.  ITTii-lBTG.  Bv  Doctors  E  H 
Clarke,  H.  J.  Bigelow,  S.  D.  Gross,  T.  G.  Thomas,  and  J.  S.  Billings.  In  one  very  hand' 
some  12tno.  volume  of  about  350  pages  :  cloth,  $2  25.  (Just  Ready.) 

This  work  has  appeared  in  the  pages  of  the  American  Journal  of  Medical  Sciences  during  the 
year  1876.  A?  a  detailed  account  of  the  development  of  medical  science  in  America,  by  gentle- 
men of  the  highest  authority  in  their  respective  departments,  the  profession  will  no' doubt  wel- 
come it  in  a  form  adapted  for  preservation  and  reference. 


JJOBLYN  (RICHARD  D.),  M.D. 

A  DICTIONARY  OF  THE  TERMS  USED  IN  MEDICINE  AND 

THE  COLLATERAL  SCIENCES.     Revised,  with  numerous  additions,  by  ISAAC   HATS, 
M.D.,  Editor  of  the  "American  Journal  of  the  Medical  Sciences."    In  one  large  royal 
12mo.  volume  of  over  500  double-columned  pages  ;  cloth,  $1  50  ;  leather,  $2  00. 
Tt  is  the  best  book  of  definitions  we  have,  and  ought  always  to  be  nponthe  cttfd«nt'i  tabl*.—  Southern 
M-.-1.  <vnd  Svrg.  Journal. 


R 


OD  WELL  (G.  F.),  F.R.A.S., 


by  n.n  Essay  or 

History  of  the  Physical  Sciences.  In  one  handsome  octavo  volume  of  694  pages,  and 
many  illustrations:  cloth,  $». 

JtfEILL  (JOHN),  M.D.,    and     VMITH  (FRANCIS  G.),  M.D., 

*•  *  Prof,  of  the  Institutes  of  Medicine  in  the  Univ.  of  Pen  na 

AN    ANALYTICAL    COMPENDIUM   OF   THE   VARIOUS 

BRANCHES  OF  MEDICAL  SCIENCE  ;  for  the  Use  and  Examination  of  Students.  A 
new  edition,  revised  and  improved.  In  one  very  large  and  handsomely  printed  royal  12m<>. 
volume,  of  about  one  thousand  pages,  with  374  wood  cuts,  cloth,  $4;  strongly  bound  in 
leather,  with  raised  bands,  $4  75. 


TJARTSHORNE  (HENRF),  M.  Z>., 

•*••*•  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

A   CONSPECTUS    OF   THE    MEDICAL   SCIENCES;   containing 

Handbooks  on  Anatomy,  Physylogy,  Chemistry,  Materia  Medica,  Practical  Medicine, 
Surgery,  and  Obstetrics.  Second  Edition,  thoroughly  revised  and  improved.  In  one  large 
royal  12mo.  volume  of  more  than  1000  closely  printed  pages,  with  477  illustrations  on 
wood.  Cioth,  $4  25  ;  leather,  $5  00.  (Lately  Itstitd.) 


We  cau  say  with  the  strictest  truth  that  it  is  the 
liest  work  of  the  kind  with  whicli  we  are  acquainted 
It  embodies  iua  condensed  form  all  recent  coutribu- 


deots,  but  to  many  others  who  may  desire  to  refresh 
their  memories  with  the  smallest  possible  expendi- 
ture of  time. — S.  Y.  Wed.  Journal,  Sept.  l>7i. 


tious  to  praciica.1  mediclo*,  »nd  is  therefore  useful   j      The  student  will  find  tbiMhe  most  convenient  and 
lo  every  busy  practitioner  throughout  oar  country,    ,  agefui  book  of  the  kind  on  which    he  can  lay  his 
besides  being  admirably  adapted  to  the  use  of  stn     j  band. — Pacific  Jfr.d  awl  tiurg.  Journ.,  Aug  1S74 
deuts  of  mediciue.     The  hook  is  faithfully  acd  ably 
executed  —Charleston  Med.  Journ  ,  April,  \-'-< 


The  work  is  intruded  as  an  aid  to  the  medical  stu 


This  is  the  best  book  of  its  kind  that  we  have  ever 
fxamined.     It  is  an   honest,  accurate,  and   conci;-* 
comppiul  of  medical   sciences,  as  fairly  an  possible 
dent,  aud  as  such  appears  to  admirably  fulfil  its  ob-  |  representing  their  present  condition.     The  chances 


ent,  aud  as  such  appears  to  admirably  fulti!  its  ob-  ;  re|irHseuting  their  present  condition.     Tl 
eel  byitsexcellent  arrangement,  thefullcompilalioo- 1  aB(j  tne  additions  have  beensojudiciousan 


of  ficts    the  perspicuity  a.,d  terseness  of  language, 
•,  pd  the  clear  and  instructive  illustrations  in"  «. nut- 
parts  of  the  work  —American  Jonrn.  of  Pharmacy, 
Philadelphia,  July,  1S74. 
The  volume  will  be  found  useful,  not  only  to  stu   | 


nd  th 


as  to  render  it. so  far  a*  it  goes,  entirely  trustworthy, 
[f  students  mast  have  ft  conspectus,  they  will  be  wise 
to  procure  that  of  Dr  Hurtshorne.— Detroit  Stv.  of 
Med  anil  Ptiarm.,  Aug  1S74. 


T  UDLOW(J.L.),  M.D. 
A   MANUAL   OF   EXAMINATIONS   upon    Anatomy,   Physiology, 

Surgery  Practice  of  Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy,  and 
Therapeutics  To  which  is  added  a  Medical  Formulary.  Third  edition,  thoroughly  revised 
and  greatly  extended  and  enlarged.  With  370  illustrations.  In  one  handsome  roysl 
12mo  volume  of  816  large  pages,  cloth,  $3  25  ;  leather,  $3  75. 

The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders      especially  suit- 
able  for  the  office  examination  of  students,  and  for  those  preparing  for  gradu 

fTANNER  (THOMAS  HA  WKES),  M.  D.,  &c. 

1  A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAO- 

NOSIS.     Third  American  from  the  Second  London  Edition.     Revised  and 
TILBURY  Fox,  M.  D.,  Physician  to  the  Skin  Department  in  University  College  Hospital, 
Ac.   In  one  neat  volume  small  12mo.,  of  about  375  pages,  cloth,  $1 

***  On  page  4,  it  will  be  seen  that  this  work  is  offered  as  a  premium  for  procuring  new 
subscribers  to  the  "  AMERICAN  JOCRNAL  or  THIS  MEDICAL  SCIENCES. 


HXNUY  C.  L«A'S  PrjBLiOATiorfs — (Anatomy). 


QRAY  (HENRY),  F.R.S., 

Ltcturtr  on  Anatomy  at  St.  Oeorge't  Hospital,  London. 

ANATOMY,  DESCRIPTIVE    AND  SURGICAL.     The  Drawings  by 

H.  V.  CARTER,  M.D.,  and  Dr  WESTHACOTT.  The  Disfections jointly  r>y  the  AtfTHOnand 
DR.  CARTER.  With  nn  Introduction  on  General  Antinomy  and  Development  >>j  T 
HOJ.MKH,  M.A..  Surgeon  to  St.  George's  Ho.«pi'al.  A  new  American,  from  the  eighth 
enlargec  and  improved  London  edition  To  which  i«  added  "  LAMIMARKN.  MEDICAI,  AI»I> 
STHGICAL,"  by  LIITIIBR  HUI.DEK.  F.R  C.S..  author  of"  Human  Osteology,"  "  A  Manual 
of  Dissections,"  etc.  In  one  map rificent  imperial  octavo  volume  of  nearly  1070  pages, 
with  622  large  and  elaborate  engravings  on  w^ood.  (N«rrly  Rtady.) 

The  author  has  endeavored  in  thin  work  to  cover  a  more  extended  range  ol  subject*  than  is  eu>* 
txnary  in  the  ordinary  text-books,  by  giving  not  only  the  details  necessary  for  the  student,  but 
also  the  application  of  those  details  in  the  practice  of  medicine  and  surgery,  thns  rendering  it  both 
»  guide  for  the  learner,  and  an  admirable  work  of  reference  for  the  active  practitioner.  The  en- 
gravings form  a  special  feature  in  the  work,  many  of  them  being  the  sire  of  nature,  nearly  nl) 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in  place  of 
figures  of  reference,  with  descriptions  at  the  foot.  They  thns  form  a  complete  and  splendid  series, 
which  will  greatly  assist  the  student  in  obtaining  a  clear  idea  of  Anatomy,  and  will  also  serve  tc 
refresh  the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling 
the  details  of  the  dissecting  room  ;  while  combining,  as  it  does,  a  complete  A  tins  of  Anatomy,  with 
a  thorough  treatise  on  systematic,  descriptive,  and  applied  Anatomy,  the  work  will  be  found  of 
essentinl  use  to  all  physicians  who  receive  students  in  their  office*,  relieving  both  preceptor  nml 
pupil  of  much  labor  in  laying  the  groundwork  of  a  thorough  medicnl  education. 

Since  the  appenrnnee  of  the  last  Ainericnn  Edition,  the  work  has  received  three  revisioss  nt  the 
hands  of  its  accomplished  editor,  Mr.  Holmes,  who  has  sedulously  introduced  whatever  has  seemed 
requisite  to  maintain  its  reputation  as  a  complete  and  authoritative  standard  text-book  and  work 
of  reference.  Still  further  to  increase  its  usefulness,  there  has  been  appended  to  it  the  recent 
work  by  the  distinguished  anatomist,  Mr.  Luther  Holden — "Landmarks.  Medicnl  and  Surgical'' 
— which  gives  in  a  clear,  condensed,  and  systematic  way,  all  the  information  by  which  the  prac- 
titioner can  determine  from  the  external  surface  of  the  body  the  position  of  internal  parts.  Thus 
complete,  the  work,  it  is  believed,  will  furnish  all  .the  assistance  that,  can  be  rendered  by  typeand 
illustration  in  anatomical  stndy.  No  pnins  have  been  spared  in  the  typographical  execution  of 
the  volume,  which  will  be  found  in  all  respects  superior  to  former  issues.  Notwithstanding  the 
increase  of  size,  amounting  to  over  TOO  pages  and  57  illustrations,  it  will  be  kept,  as  heretofore, 
at  a  price  rendering  it  one  of  the  cheapest  works  ever  offered  to  the  American  profession. 

ALSO  FOR  SALE  SEPARATE 


TJOLDEN  (LUTHER),  F.R.C.S., 

Surge  tn  tt  fit.  B  irthtlotnew  8  and  the  Fwwlling  Hn»p<tif#. 

LANDMARKS,  MEDICAL  AND  SURGICAL.    From  the  2d  London 

Ed.    In  one  handsome  volume,  royal  12mo.,  of  128  pages  :  cloth,  88  cents.    (Note  Ready.) 


The  title  of  thin  book  In  very  suggestive  of  lt« 
v  radical  valne,  while  the  peromil  of  the  work  itself 
t-xrifiei  the  moat  extravagant  expectations.  The 
bjfd  of  the  Author  bat  keen  to  collect  in  compact 
'•in  the  landmarks,  or  surface-marks  off  be  different 
j'iirti-  of  tli?  body,  and  indicate  their  relation  to  the 
<  eeper-seated  parti.  The  valne  of  this  sort  of  know- 
ledge to  the  physician,  but  especially  to  the  gnrgeon 
wl  o,  with  anatomical  eye,  can  make  the  ti.tsne* 
transparent  before  him,  is  incalculable.  The  nap- 
ping nut  of  the  tinman  body  is  one  which  is  moxt  in- 
structive to  the  practical  man,  and  he  is  enabled, 
after  considerable  experiei.ce,  to  have  landmark* 
of  Ms  own;  but  in  the  little  work  before  us  this 
knowledge  is  systematized  in  Mich  an  intelligible 
manner  an  to  :  lace  it  within  tbe  reach  of  all  It  is 
one  of  the  most  InUiestiug  little  works  we  have 


ffia  for  a  long  time.—  ft.  Y.  Sfed.  Record,  May  11, 
1878. 

Of  all  tbe  recent  new  works  published  we  have 
no  h«  itancy  in  declaring  this  by  far  the  moM  rain- 
able  to  every  practitioner.  Tht  author  his  here 
given  a  series  of  landmarks  that  will  enable  one  to 
locale  with  certainty,  by  means  of  external  appear- 
ances, nearly  every  important  purt  practically  con- 
sidered in  tbe  body.  We  would  ad  vise  every  practi- 
tioner to  procure  a  copy,  and  keep  it  always  by  him. 
—JfathvilleJ»urn.  >fMtd.andSvrg.r<s\>.  1S78. 

'1'iiii  little  work  is  a  inont  valuable  collection  of 
plain,  simple,  and  practical  dints;  it  contains  in- 
struction which  will  be  invaluable  to  the  busy  prac- 
titioner as  well  BJ  to  the  wludvnt  of  medicine,  and 
w«  heartily  commend  It  to  our  readers. — Canadn 
Stud.  and  Sitry.  /<>«rn.,  April,  1.S7S. 


QMITH  (HENRY  H.),  M.D.,         and     UORNER  (  WILLIAM  E.),  M.D., 

Pro/.  <»/  Surgery  in  t  he  Univ.  o/Pennu.,Ae.  '     LattPruf.  of  Anatomy  in  the  Univ.  ofPenna.,  Ac 

AN    ANATOMICAL    ATLAS,  illustrative  of  the   Structure  of  the 

Human  Body.     In  one  volume,  large  imperial  octavo,  cloth,  with  about  six  hundred  and 
fifty  beautiful  figures.     $4  50. 


HORHER'SSPECIAL  AHATOMY  AHD  HISTOLOGY.  fSHARPET  AND  QUAIL'S  HCMA*  AJfATOMT.  Re- 
Eigbtb  editiom,  ext»n«iv»lT  r*tvtnpd  and  rm.difeH  ;  vi*ed,  with  Holes  and  Additions,  by  JOSKPH  LKJDT, 
In  2  Tolft.  Svo  ,  of  OTerlOOO  pages,  with  330  wood-  ,  M  D.,  Professor  of  Anatomy  in  the  Uuiverxity  of 
cuts  :  cloth,  ffi  oo  ;  Pennsylvania  Complete  in  two  large  octavo  vol- 

HODfJES'    PRACTICAL     DISSECTIOIfS.        Second'      nn.es   of  about  1300  pag.es,  wi:h  511  illu»trati»Bsj 
Kdition,  thoroughly  revised.     In   one   Deal  royal  (     «l«th,*600. 
Umo.  volume,  half  bound,  $2  00.  /   4ni 


HENRY  C.  LEA'S  PUBLICATIONS— (Anatomy). 


A  LLEN  (HARBISON,  3/.Z>.), 

-^•*-  Proffgxnr  of  Comparative  Anatomy  and  PhysioUtgy  in  th».  Univ.  of  Pa. 

A  SYSTEM  OF  HUMAN  ANATOMY:  INCLUDING  ITS  MEDICAL 

and  Surgical  Relations.    For  the  Use  of  Practitioners  and  Students  of  Medicine.     With  nn 
Introductory  Chapter  on  Histology.    By  E.  0.  SHAKESPKAUE,  M  D  ,  Ophthalmologist  to  the 
Phila.  IIosp.     In  one  large  and  handsome  quarto  volume,  with  several  hundred  original 
illustrations  on  lithographic  plates,  and  numerous  wood-cuts  in  the  test.      (Preparing.) 
In  this  elaborate  work,  which  has  been  in  active  preparation  for  several  years,  the  author  hag 
sought  to  give,  not  only  the  details  of  descriptive  anatomy  in  a  clear  nnd  condensed  form,  but  also 
the  practical  applications  of  the  science  to  medicine  and  surgery.    The  work  thus  has  claims  upon 
the  attention  of  the  general  practitioner,  as  well  as  of  the  student,  enabling  him  not  only  to  re- 
fresh his  recollections  of  the  dissecting  room,  but  also  to  recognize  the  significance  of  all  varia- 
tions from  normal  conditions.     The  marked  utility  of  the  object  thus  sought  by  the  author  is 
self-evident,  and  his  long  experience  and  assiduous  devotion  to  its  thorough  development  are  a 
sufficient  guarantee  of  the  manner  in  which  his  aims  have  been  carried  out.     No  pains  have  been 
spured  with  the  illustrations.     Those  of  normal  anatomy  are  from  original  dissecti  jns,  drawn  on 
stone  by  Mr.  Hermann  Faber,  with  the  name  of  every  part  clearly  engraved  upon  the  figure, 
after  the  manner  of  "  Holden"  and  "Gray"  and  in  every  typographical  detail  it  will  be  the 
effort  of  the  publisher  to  render  the  volume  worthy  of  the  very  distinguished  position  which  id 
aaticipated  for  it. 

.XTILSON  (ERASMUS},  F.R.S. 

A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.    Edited 

by  W.  H.  ftocHKCHT,  M.  D.,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  Col- 
lege of  Ohio.  Illustrated  with  three  hundred  and  ninety-seven  engravings  on  wood.  In 
one  large  and  handsome  octavo  volume,  of  over  600  large  pages  ;  cloth,  $4  j  leather,  $5. 

TIE  A  TH  (CHRISTOPHER),  F.  R.  €.  S., 

•*-*.  Teacher  of  Operative  Surgery  in  University  College,  London. 

PRACTICAL   ANATOMY:   A   Manual   of  Dissections.     From   tbe 

Second  revised  and  improved  London  edition.  Edited,  with  additions,  by  W.  W.  KEEN. 
M.  D.,  Lecturer  on  Pathological  Anatomy  in  the  Jefferson  Medical  College,  Philadelphia 
In  one  handsome  royal  12ino.  volume  of  578  pages,  with  247  illustrations.  Cloth  $3  50  ; 


DELLAMF(E.),  F. R, C.& 

THE  STUDENT'S  GUIDE  TO  SURGICAL  ANATOMY:  A  Text- 
Book  for  Students  preparing  for  their  Pass  Examination.  With  engravings  on  wood.  In 
one  handsome  royal  12mo.  volume.  Cloth.  $2  25.  (Lately  Published.) 


We  welcome  Mr.  Bellamy  s  work,  as  a  contribu- 
tion to  the  study  of  regional  anatomy,  of  equal  value 
to  the  student  and  the  surgeon.  It  is  written  in  a 


clear  and  concise  style,  and  its  practical  suggestions 
idd  largely  to  theinterest  attaching  to  its  technical 
details  — Chicago  Mtd.  Examiner,  MarcL  1,  1674. 


C 


'LELAND  (JOHN),  M.D., 

Professor  of  Anatomy  and  Physiology  in  Queen's  College,  Galwntf. 

A   DIRECTORY   FOR  THE    DISSECTION  OF  THE   HUMAN   BODY. 

In  one  small  volume,  royal  12mo.  of  182  pages :  cloth,  $1  25.     (Just  Issued.) 
This  is  a  plain,  convenient,  dissecting  guide,  to  be  I  in  common  use,  bat  merely  supplements  them    and 
-serf  over  tbe  subject      As  such,  it  will  command  it    I  prppan*  the  dissector  (or  many  pracncal  dilliculnes 
"elf  to  tb«  student  by  the  lucid  composition  and  dis-  |  thatare  apt  to  perplex  t  ,«  inexperienced. 

&e  1 1  IV  l  ii-c  ov«w<3n         j  i  ironion  r  «!?*•  fur  cu  rrvlntr  1  11   t  ha  n.trkal     Mini    Oi,m 


tinct   directions  of   the  author.— Jfed.  and.  Surg 
Rf.porter,  Feb.  1S77. 
This  volume  does  not  interfere  with  the  text-books 


coureiiientHize  for  carrying  iu  the  pocket,  and  should 
be  iu  liie  possession  of  every  student  of  medicine. - 
K.  Y.  Mud.  Journ.,  March,  1877 


QCHAFER  (EDWARD  ALBERT),  M.D., 

O  Assistant  Prof etsor  of  Physiology  in  University  Ootloge,  London. 

A  COURSE  OF  PRACTICAL  HISTOLOGY:  Being  an  Introduction  to 

the  Use  of  the  Microscope.     In  one  handsome  royal  12mo.  volume  of  304  pages,  with 
numerous  illustrations  :  cloth,  $2  00.     (Jnst  Issued.) 
We  are  very  mrbp,^f^he^u,b^     h^ha^s^^^  Jhe  ^^h^^ the^tU, 

ss^«« 

microscopic  anatomy  of  the  tissues  and  W*  <>  ™  '*  «' '  ir    ecfion  or  pa.ag.aph  from  any  one  else.    Even 

absolutely  necessary    .^^L^S^S^M,  \  w hen  de^cribingso.ne  of  the,,,, ones,  process,..  * 

it  is  the  way  in  which  it  takes  th«stu   eiit ^  ™™™'  '  6UOWb  ,uch  ft  practical  familiarity  with  the, 

as  it  were,  showing  him  what  to  do,  and  «*P'»m"^  «s  to  give  his  description  the  flavor  of  originality.    In 

simply,  but  thoroughly,  how  to  do  it.-Oost  nMed.an*    ,  ^^  W(j  cau  ionddently  .ecommend  ibeWk 

Surg.  Journ.,  April,  1S7/.  as  t))e  mo(jt  U!ieful  ,,,anual  f.ir  the  practical  hisiol.j- 

As  a  whole,  the   book  is  an  admirable  one.    1        ,  Rist  w,th  which  we  are  acqua  nted.— Chicago  .V->1. 

descriptions  are  brief,  but  they  are  clear  and  de'i  journ.  and  Exam.,  Sept.  1377. 
ed     The  author  has  learned  the  art  of  stopping  when 


HBNBY  C.  LEA'S  PUBLICATIONS— (Physiology). 


riARP  ENTER  (WILLIAM  B.),  M.D.,  F.R.S.,,F.G.S.,  F.L.S., 

v  SepMrar  to  Univtrtity  of  London,  etc. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  Edited  hy  II KXKY  TOWER, 

M.B.  Lond.,  P  R.C.S.,  Examiner  in  Natural  Science*,  University  of  Oxford.     A  new 
American  from  the  Eighth  Revised  and  Enlarged  English  Edition,  with  Jiotes  and  Addi- 
tions, by  FRANCIS  Q.  SMITH,  M.  D.,  Professor  of  thelLstitntescf  Medicine  in  the  Univer- 
sity of  Pennsylvania,  etc.    In  one  very  large  and  handsome  octa^  volume,  of  1083  pages, 
with  U  opiates  and  373  engravings  on  wood;  cloth, $5  60;  leather,  $6  50.     (Just  Istiitd.) 
The  great  work,  the  crowning  labor  of  the  distinguished  nnthnr.  and  through  which  so  many 
generations  of  students  have  acquired  their  knowledge  of  Physiology,  has  been  almost  met:imor 
phosed  in  the  effort  to  at  opt  it  thoroughly  to  the  requirements  oi  modern  science. 
appearance  of  the  last  American  edition,  it  has  had  several  revisions  at  the  experienced  hiind  of 
Mr.  Power,  who  has  modified  and  enlarged  it  »o  as  to  introduce  all  that  is  importnnt  in  the 
investigations  and  discoveries  of  England,  France,  and  Germany,  resulting  in  an  enlargement  of 
about  one-fourth  in  the  text.     The  series  of  illustrations  has  undergone  a  like  revision,  a  large 
proportion  of  the  former  ones  having  been  rejected,  and  the  total  number  increased  to  nearly 
four  hundred.     The  thorough  revision  which  the  work  has  so  recently  received  in  England,  hag 
rendered  unnecessary  any  elaborate  additions  in  this  country    but  the  American  Editor,  Pro- 
fessor Smith,  has  introduced  such  matters  as  his  long  experience  has  shown  him  to  be  requisite 
for  the  student.     Every  cure  has,  been  taken  with  the  typographical  execution,  and  the  work  is 
presented,  with  its  thousand  closely,  but  clearly  printed  pages,  as  emphatically  the  text-bonk  for 
the  student  and  practitioner  of  medicine — the  one  in  which,  as  heretofore,  especial  care  is  directed 
to  show  the  applications  of  phy.  iology  in  the  various  practical  branches  of  medical  science. 
Notwithstanding  its  very  great  enlargement,  the  price  has  not  bet n  increased,  rendering  this 
one  of  the  cheapest  works  now  before  the  profession. 

We  hare  been  agreeably  surprised  to  find  the  vol- 
ume so  complete  in  regard  to  the  structure  and  func- 
tions of  the  nervous  system  in  all  its  relations,  a 
btibject  that,  in  many  respects,  isoueof  the  most  diffi- 
cult of  all,  in  the  wh.'le  range  of  physiology,  upon 
which  to  produce  a  fall  and  satisfactory  treatise  of 
the  class  to  which  the  one  before  us  belongs.  The 
additions  by  the  American  editor  give  to  the  work  as 
it  is  a  cou»ider»ble  value  beyond  that  of  thi  list 
English  edition.  In  conclusion,  we  can  give  our  cor- 
dial recommendation  to  the  work  us  it  now  appears. 
The  editors  have,  with  their  additions  to  the  only 
work  on  physiology  in  our  language  that,  in  the  full- 
est M-u-e  of  the  word,  la  the  production  of  a  philoso- 
pher as  well  as  a  physiologist,  brought  it  up  as  fully 
as  could  be  expected,  if  nut  desired,  to  the  standard 
of  onr  knowledge  of  its  subject  at  the  present  day. 
It  will  deservedly  maintain  the  place  it  his  always 
bad  in  the  favor  of  the  medical  profession. — Journ. 
of  Nervous  and  Mental  Di>tane,  April,  1877. 


••(iood  wine  ne«ds  no  bush"  says  the  proverb,  and 
an  old  and  faithful  servant  like  tlie  ••  big"  Carpenter,  as 
carefully  brought  down  at)  this  edition  lias  be«n  by  Mr. 
Henry  Power,  needs  little  or  no  commendation  by  us. 
Such  onoruious  advances  have  recently  been  made  in  our 
l'hvsi'.l"i;iral  knowledge,  th.-it  what  was  perfectly  new  a 
year  or  two  ago.  looks  now  as  if  it  had  been  a  received 
»nd  established  fnct  for  years.  In  this  encyclopa-dic 
way  it  is  unrivalled.  Here,  iv  it  seems  to  us,  is  the 
great  value  of  the  book:  one  is  safe  In  sending  a  student 
to  it  for  information  on  almost  any  given  subject,  per- 


fectly certain  of  the  fulness  of  Information  it  will  con- 
vey, and  well  satisfied  of  the  accuracy  with  which  it  will 
there  be found  stated. — London  Med.  Times  antl 
Feb.  17,  1870. 

Th  UK  fully  ore  treated  the  strncture  and  functions  of  all 
thi)  important  organs  of  tht;  body,  while  there  are  chap- 
ters on  sleep  and  somnambulism;  chapterson  ethnology  . 
a  full  section  on  (jeneraiion.  and  abundant  references  to 
the  curiosities  of  physiology,  as  the  evolution  of  light, 
heat,  electricity,  etc.  In  short,  this  new  edition 
penter  i-i,  as  we  have  said  at  the  start,  a  very  encyclo- 
pedia of  modern  physiology.—  The  Clinic,  Feb.  24, 1K77. 


The  merits  of  "Carpenter's  Physiology  are  so  widely 
known  and  appreciated  that  we  need  only  allude  lini-tly 
to  the  fact  that  inthelatest  edi  ion  will  be  found  a  com- 
prehensive embodiment  of  the  results  of  recent  phytio- 
lonical  investigation.  Care  has  been  tukeu  to  preserve 
the  practical  character  of  the  original  work.  In  fact 
the  entire  work  has  been  brought  up  to  date,  and 


evidence  of  the  amount  of  labor  that  has  been  bestowed 
upon  it  by  its  distinguished  i-litor.  Mr  Henry  Power. 
The  American  editor  has  made  the  latest  additions,  in 
order  fully  to  cover  the  time  that  has  elapsed  since  the 
last  English  edition.— JV.  Y  Mr.d  Journal,  Jan.  Ih77. 

A  more  thorough  work  on  physiology  could  not  be 
found.  In  this  all  th«  facts  discovered  by  the  late  re- 
searches are  noiiced.  and  neither  student  nor  practi- 
tioner should  be  without  this  exhaustive  treatise  on  an 
rn..  rt:int  elementary  branch  of  medicine. — Atlanta 
Med.  anil  Surg.  Journal,  Dec.  1876. 


ITIRKES  (WILLIAM  SENHOUSE),  M.D. 

A  MANUAL  OF  PHYSIOLOGY.     Edited  by  W.  MORRANT  BAKER, 

M.D.,  F.R.C.8.  A  new  American  from  the  eighth  and  improved  London  edition.  With 
about  two  hundred  and  fifty  illustrations.  In  one  large  and  handsome  royal  12mo.  vol- 
ume. Cloth,  $3  25;  leather,  $3  75.  (Lately  issued.) 

Kirkes'  Physiology  has  long  been  known  as  a  concise  and  exceedingly  convenient  text-book, 
presenting  within  a  narrow  compass  all  that  is  important  for  the  student.  The  rapidity  with 
which  successive  editions  have  followed  each  other  in  England  has  enabled  the  editor  to  keep  it 
thoroughly  on  a  level  with  the  changes  and  new  discoveries  made  in  the  science,  and  the  eighth 
edition,  of  which  the  present  is  a  reprint,  has  appeared  so  recently  that  it  muy  be  regarded  as 
the  latest  accessible  exposition  of  the  subject. 

On  the  whole,  there  is  very  little  in  the  book    the   hands  of  students.  —  Boston  Med.  and  8ura. 
which  eltherthe  student  or  practitioner  will  notflnd    Journ.,  April  10  18T3 
of  practical  value  and  consistent  with  onr  prexeut        ,     . 

knowledge  of  th.srapidly  changing  science;  and  we    .    ^  »ts  enlarged  form  it  is,  in  onr  op  nion,  s til    the 
have  no  hesitation  in  expressing  our  opinion  that    best  book  on  phy«iol,.gy,  most  useful  to  the  student, 
this  eighth  edition  is  one  of  the  best  handbooks  on    ~PMla-  **<*•  Time*,  Aug.  30,  1873. 
physiology  which  we  have  in  onr  language. — If.  T.        This  is  undoubtedly  the  best  work  for  students  of 
JTed.  Record,  April  15,  1873.  physiology  extant.— Cincinnati  Mid.  Sews,  Sept.  '73. 

The   book  is  admirably  adapted  to  be  placed  In 


fJARTSHORNE  (HENRY),  M.D., 

•*••*-  Professor  of  Hygiene,  etc  ,  in  the  Univ.  ofPenna. 

HANDBOOK  OF   ANATOMY  AND   PHYSIOLOGY.     Second  Edi- 

tion,  revised.   In  one  ro.yal  12mo.  volume,  with  220  wood-cuts :  cloth,  $1  75.   (Juit  Issuid.) 


HKNB.Y  C.  LEA'S  PUBLICATIONS — (Physiology).  9 

n ALTON  (J.  C.},  M.  D., 

•*-'  Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  Ntw>  York,  Ac. 

A  TREATISE  ON  HUMAN  PHYSIOLOGY.   Designed  for  the  use 

of  Students  and  Practitioners  of  Medicine.  Sixth  edition,  thoroughly  revised  and  enlarped, 
with  three  hurired  and  sixteen  illustrations  on  wood.  In  one  very  beautiful  octavo  vol- 
ume, of  over  800  pages.  Cloth,  $5  50  ;  leather,  $6  50.  (Just  Itsitcd.) 

From  the  Prefa-te  to  the  Sixth  Edition. 

In  the  present  edition  of  this  book,  while  every  part  hns  received  a  careful  revision,  the  ori- 
ginal flan  of  arrangement  has  been  changed. only  so  far  as  was  necessary  for  the  introduction  of 
new  material. 

The  additions  and  alterations  in  the  text,  requisite  to  present  concisely  the  growth  of  positive 
physiological  knowledge,  have  resulted  in  spite  of  the  author's  earnest  efforts  at  condensation, 
in  an  increase  of  fully  fifty  per  cent,  in  the  matter  of  the  work.  A  change,  however,  in  the  ty- 
pographical arrangement  has  accommodated  these  additions  without  undue  enlargement  in  the 
bulk  of  the  volume. 

The  new  chemical  notation  anrl  nomenclature  are  introduced  into  the  present  edition,  ss  hav- 
ing now  so  generally  taken  the  place  of  the  old,  that  no  confusion  need  result  from  the  change. 
The  centigrade  system  of  measurements  for  length,  volume,  and  weight,  is  also  adopted,  these 
measurements  being  at  present  almost  universally  employed  in  original  physiological  investiga- 
tions and  their  published  accounts.  Temperatures  are  given  in  degrees  of  the  centigrade  scale, 
usually  accompanied  by  the  corresponding  degrees  of  Fahrenheit's  scale,  inclosed  in  brackets. 

MEW  YORK,  September,  lS7.i. 

Durinjr  the  p»st  fe»-  years  several  new  works  on  pby-'  This  popular  tcx'-book  on  physiology  comes  to  us  in 
Ijtions  of  old  works,  have  appeared,  its  sixth  edition  with  the  addition  of  about  fifty  percent, 
competing  for  the  lavorof.tii*  raeilkal  student,  but  none  of  new  matter,  chiefly  iu  the  departments  of  patho- 
wi!l  rival  this  IK-W  edition  of  Daltnn.  As  now  enlarged,  logical  chemistry  and  the  nervous  system,  where  the 
it  will  he  found  aJso  to  be. in  general,  a  satisfactory  work  principal  advances  have  been  re.nli/«d.  With  so  tho- 
of  refereooe  for  the  practitioner. — Chieayo  Jled.'jwarn. ,  rough  revision  and  addi'ious.  thxt  keep  the  work  well 
«nrf  Etui  miner.  .Ian.  <  :  up  to  the  times,  its  continued  popularity  may  he  ennfi 

^±^^.^^3±±^1  H^S^l^^Ssi"'1' 

fairness,  a  fulness.  a,Kl  a  oon<-i<enes*  wbioh  *n,l  fre^h-  «"««—«'•  £™IS  *f"'-  «'"'  •*"»•  J"*™  -  »«c.  1WS 
ness  mid  vijjor  to  tii<?  eniir<?  hook.  Rut  hi-  discussions  W"6  heartily  welcome  this,  the  sixth  edition  of  this 
have  beeu  so  guarded  hv  «  refuel  of  admission  to  tlio«-  idrair&ble  text  book,  than  which  there  are  none  of  e^uat 
speculative  and  theoretical  explanations,  which  ai  l«-st  brevity  mor«;  valuable.  It  is  cordially  recommended  l>y 
exist  in  the  minds  of  observers  themselves  as  only  pro- '  th«  Professor  of  Physiolojy  in  the  University  of  I.,  ni.-i- 
babilities.  that  none  of  his  readers  need  he  led  into  ana.  as  by  all  competent  teacher*  in  the  United  State* 
p-ave  error-  white  makitg  them  a  study.— The  iMical ,  !ln(1  wherever  the  RngHxb  language  is  read,  this  book 
Recoi-rf.  Feb  19  1876  has  been  appreciated.  The  present  edition,  with  it*  3l« 

l^erevisionof  ,hi?rrtwork  has  brought  it  forward  |  ^&™^^^£^  £f^ 
with  th«  phys^U^al  advancesof  tb«  day.  and  renders  ^ffm  psrwptiblv  in.-reaswl.-A'w  Orleuns  todical 

tt,  as  it  ba^ver  l»een.  the  fii^st  wovk  for  studen<S  ex-  j        ,  Surreal  J«".™t.  Mnreh.  1876. 
Unt. — Aa,<*ttWc  Jrtarn.  n/Mflrf.  <ntrf  Sura..  Jan.  1876. 

The  present  edition  is  verv  much  superior  to  every 

For  Clear***  and  perspicuity .  Dal  ton's  Phyno!Offy  j  othftr  not  on|y  .„,  that  u  hrjn  the  sut.jeet  up  to  tb« 
?o«oiended  itself  to  the  student  years  »Kn.  and  was  a  ,  tiri|OS  but  th/t  it  d. ...  ,0  mor(.  fllllv  nm,  ^ttActoHIt 
pleassnt  r«hef  from  the  verbose  prodnclirms  which  it  thjin  M1VpreViOUS(Hiition.  Takeit  «ltogH.her.it  ren.ainti 


Fiipplanted.     Physi'iic^rv  h:is.  rmwever.  made  many  ad- 
vances since  then  — »nd  white  th«  style  has  been  pre- 


in  our  hum  hie  opinion,  the  best  text  book  on  pbysiolojjy 
in  any  land  or\aniua'j« — The  Clinic,.  Nov.  6,  ]876. 


served  intact,  tho  work  in  the  present  edition  has  been  , 

rtrouzht  upfullvahreastof  the  times.  Tbe  new  chemical  j      AF  *  »bole.  we  cordially  recommend  the  work  as  • 

notation  and  n^nen^ature  hare  aU,.  i.ee,,  intrndu.«<l  i  text  hook  for  the  student   »nd   as   one  of  the  best.— 


lato  the  present  edition.     Notwithstanding  the  multi- 
plicity of  text-l^ooks  on  phyMnlosy.  this  will  lose  none 


Tfif,  Journal  nflfemm*  and  Mtntal  Dit'aft,  Jan.  1S76. 
Still  liolOs  its  position  a<  a  mHsterpii'ce  of  lucid  writ- 


<sf  its  old  time  popularity.  The  mechanical  execution  inf.  and  is,  we  believe,  on  the  whole,  the  best  book  to 
of  the  work  is  all  that  could  be  desired. — fcninsuJaj  j  place  in  the  hands  of  the  student. — LoncUm  Student? 
Journal  nf  Medicine,  Dec.  1875.  I  Joiimaf. 

J)UNGLISON  (ROBLEY),  M.D., 

-*-^  Proftasor  of  Tn*titiute*  of  Medicine  in  Jefferson  MrMcal  flollege,  Philadelphia. 

HUMAN  PHYSIOLOGY.     Eighth  edition.    Thorouirhly  revised  and 

extensively  modified  and  enlarged,  with  five  hundred  and  thirty-two  illustrations.     In  two 
large  and  handsomely  printed  octavo  volumes  of  about  1500  pages,  cloth,  $7  00. 

T  EHMANN  (C.  <?.). 

PHYSIOLOGICAL  CHEMISTRY.  Translated  from  the  second  edi- 
tion by  GEORGE  E  DAT,  M.  D.,  F.  R.  S.,  Ac.,  edited  by  R.  E.  ROGERS,  M.  D.,  Professor  of 
Chemistry  in  the  Medical  Department  of  the  University  of  Pennsylvania,  with  illustration* 
wslected  from  Funke's  Atlas  of  Physiological  Chemistry,  and  an  Appendix  of  plates.  Com- 
plete in  two  large  and  handsome  octavo  volumes,  containing  1200  pages,  with  nearly  two 
hundred  illustrations,  eloth,  $6  00. 


B 


T  THE  SAME  AUTHOR. 

MANUAL  OF  CHEMICAL  PHYSIOLOGY.     Translated  from  the 

CUrman,  with  Notes  and  Additions,  by  J  CHESTOH  MORRIS,  M.  D.,  with  an  Introductory 
Essay  on  Vital  Force,  by  Professor  SAMDBL  JACKSON,  M.  D.,  of  the  University  of  Pennsyl- 
vania. With  illustrations  on  wood.  In  one  Tery  haodaome  octavo  volume  of  336  pages, 
eloth,  $2  26. 


10 


C.  LBA'S  PaeLiOATioifs — (Ohenvistry). 


ATTFIELD  (JOHN},  Ph.D., 

Priifefitr  of  Practical  Chemistry  to  tht  PkarmaemUtml  Society  of  OrtfU  Britain,  Ac. 

CHEMISTRY,   GENERAL,  MEDICAL, .AND   PHARMACEUTICAL; 

including  the  Chemistry  of  the  U.  8.  Pharmacopoeia.     A  Manual  of  the  General  Principles 
of  the  Science,  and  their  Application  to  Medicine  and  Pharmacy.      Seventh  American  edi- 
tion, reviser  from  the  Sixth  English  edition  by  the  author.     In  one  handsome  royal  12mo. 
volume  of  668  pages,  with  87  illustrations  :  cloth,  $2  75  ;  leather,  $3  26.      (Just  Issued.)  . 
This  work  hn  s  received  a  very  careful  revision  at  the  hands  of  the  author,  resulting  in  a  conside- 
rable increase  in  size,  together  with  the  addition  of  11  hundsoine  series  of  illustrations      Nojwith- 
stitnding  these  improvements,  the  price  has  been  maintained  at  the  former  very  moderate  rate. 


It  is  a  valuable  work  for  tbe  busy  practitioner,  eat- 
eluding  an  it  does  everytbiug  that  would  be  of  inie- 
reat  only  to  the  scientific  chemist,  aod  having  a  com- 
prehensive index  wlm-h  render!*  after  consultation 
eaay.  That  portion  devoted  t"  nrlnalyvin  and  prac- 
tical toxicology,  and  tbe  tests  for  impurities  io  medi- 
cinal preparations,  is  especially  valuable  to  the 
practising  physician  Fur  tbe  student  it  is  desirable, 
for  the  reason  that  it  i«  so  arranged  thai  he  may, 
without  an  inst 'nc'or,  study  the  science  experiment- 
ally  Am.  l*ritctni»aer,  March,  1S77. 

Aft^r  having  used  it  as  a  text-book  in  the  laboratory 
of  the  Philadelphia  Toilette  of  Pharmacy  during  the  last 
flve  years,  we  can  speak  from  our  own  experience,  and 
testify  to  its  intrinsic  value  in  the  instruction  of  the 
student.  The  more  we  hare  used  it,  the  more  we  were 
pleased  with  it.  and  on  theappearaneeof  anew,  revised, 
and  enlarged  edition,  we  take  occasion  to  a^nrii  cordi- 
ally recommend  it.  believing  that  for  tbe  practical  in- 
*  trui- 1 1  on  of  pharmaceutical  students  in  chemistry  it 
has  no  superior  in  the  English  language.— Am.  Jottrn. 
•/  Pliarrn.,  NOT.  1878. 

Tbe  book,  by  a  well  arranged  system,  Introduces  the 
student  into  the  Science  of  Chemistry.  Kivinsf  him  at 
each  ••tep  sufficient  information  to  enable  him  lo  per- 
form experiment^  with  his  own  hands;  theexperiments 
are  partly  of  synthetical  and  partly  of  analytical  inte- 
rest: in  thin  way  the  editor  succeeds  admirably  in 
avoiding  a  dry  monotonous  enumeration  of  Tacts.  The 


v:tri<-ly  which  he  cives  U  corluinly  well  rnlruhttetf  to 
prevent  the  render  from  utttintf  tjred.  This  variety, 
however,  is  not  such  as  to  bewilder  the  mind,  nor  are 
'he  experiments  dearrilietl  calculated  only  to  nerve  as  a 
pleasant  pastime.  The  student  who  reads  the  book  and 
executes  the  experiments  mentioutvl.  rannnl  help  but 
fee  I  deeply  interested  in  the  subject,  aud  indeetl.  will, 
^oin^  through  the  practical  work,  find  it  a  very  ngrce- 
able  recreation.— 'Cincinnati  Clinic,  Oct.  28.  1876. 

It  brings  up  oar  knowledge  of  tbe  subject  to  the  pre- 
sent dute.  and  has  been  enriched  with  numerous  wood 
en  urn  vinir*  ill  u-  trntive  of  apparatus  and  modes  of  work. 
The  arrangement  of  the  wnrk  is  ;i,lmir:i>.l.-.  anil  to  cai-b 
element  'ts  more  important  compounds  used  in  uifdi- 
cineor  pharmacy  nreiiiven,  together  with  both  syntheti- 
cal ami  nnalyrim)  reactions.  The  systematic  analysis 
of  componn<j«.  substnnces  or  ffnids  is  also  treated  of. 
!iixl  copious  tables  are  ^iven  showing  the  modes  of  sy»- 
temntically  separating  th«  dilferent  i-lements  from  one 
another. —  ftmntla  JHed.  and  Surp.  Jmim  ,  NOT.  is"!'-. 

As  a  compact  manual  of  the  treneral  principles  of  the 
science  and  their  applications  in  medicine  and  phar- 
macy  it  has  no  riTsl.  and  the  frequent  and  thoronuli 
revision  it  receives  keeps  it  m  all  rt-speet«  up  with  the 
times  The  American  edition,  which  covers  tbt>  Unit  0 
States  Pharmacopoeia,  is  prepared  under  the  sinllmr  » 
supervision  — »>»tnn  Journal  of  Cfirniitry.  NOT  |s76. 

A-lmirably  adapted  to  the  use  of  medical  students.— 
Atlanta  M#l.  J»«77>.,Oct.  1376. 


pt^WNES  (GEORGE),  Pk.D. 

A  MANUAL  OF  ELEMENTARY  CHEMISTRY;  Theoretics]  and 

Practical.  Revised  and  corrected  by  HKURT  WATTS,  B.A.,  F  R.S.,  anthor  of  "  A  Diction- 
ary of  Chemistry,"  etc.  With  a  colored  plnte,  and  one  hundred  and  seventy-seven  illus- 
trations. A  new  American,  from  thf  twelfth  nnd  enla-gel  London  edition.  Edited  by 
ROBICRT  BRIDGES,  M.D.  In  one  larpe  royal  12ino.  volume,  of  over  IftOO  pages. 
(Nearly  Ready.) 

Two  careful  revisions  by  Mr.  Wnfts,  since  the  appearance  of  the  !.•>*».  American  edition  of 
"  Fownes,"  have  so  enlarged  the  work  that  in  England  it  has  been  divided  into  two  volumes  In 
reprinting  it,  by  tbe  use  of  a  small  and  exceedingly  clear  type,  cunt  for  the  porp-  se,  it  has  been 
found  possible  to  comprise  the  whole,  without  omission,  in  one  volume,  not,  unh.tndy  fir  study  sml 
reference.  The  enlargement  of  the  work  has  induced  the  American  Editor  to  confine  his  :i Editions 
to  the  narrowest  compass,  and  be  bus  accordingly  inserted  only  such  discoveries  iis  h.-ive  been  an- 
nounced since  the  very  recent  nppesmnee  of  the  work  in  England,  and  has  adder  the  standards 
in  popular  use  to  the  Decimal  and  Centigrade  systems  employed  in  the  origir.nl.  ' 

Among  the  additions  to  this  edition  will  he  found  a  very  handsome  colored  plnte,  representing 
a  number  of  spectra  in  the  spectroscope.     Every  care  has  been  taken  in  the  typographical  execn 
lion  to  render  the  volume  worthy  in  every  respect  of  its  high  reputation  nnd  extended  use,  nnd 
though  it  hns  been  enlarged  by  more  thnn  one  hundred  nnd  fifty  p:tges,  its  verv  moderate  price 
will  still  maintain  it  as  one  of  the  cheapest  volumes  accessible  to'th»  chemical  student. 


T>OWMAN  (JOHN  E.),  M.  D. 
PRACTICAL  HANDBOOK  OP  MBDICAL  CHEMISTRY.     Edited 

by  C.  L.  BI.OXAM,  Professor  of  Practical  Chemistry  in   King's  College,  London.      Sixth 
American,  from  the  fourth  and  revised  English  Edition.     In  one  neat  volume,  royal  12mo. , 
pp.  351,  with  numerous  illustrations:  oloth,  S3  25. 
gl'  TUK  SAMB  AUTHOR.    (Laf-ly  lnont-d.)        

INTRODUCTION   TO   PRACTICAL  CHEMISTRY,  INCLUDING 

ANALYSIS.     Sixth  American,  from  the  sixth  and  revised  London  edition.    With  numer- 
ous illustrations.     In  one  neat  vol.,  royal  12mo.,  oloth,  $2  25. 


KSiPP'S  TECHNOLOGY  ;  or  ChemiBtry  Applied  te  I     r«ry  handsome  octavo   voloroes,  with   500  wood 
the    Arts,  and   to  MannfactnreB.    With  American  I     engravings,  cloth   $6  00. 
additions  by  Prof.  WALTER  R.  JOHNSON,     la  two  I 


HENRY  C.  LEA'S  PUBLICATIONS — (Chemistry). 


11 


J2LOXAM  (C.  £,.), 

Pri>fe.s*<ir  of  dh*rnixtry  in  King's  College.  London. 

CHEMISTRY,  INORGANIC  AND  ORGANIC. 


From  the  Second  Lon- 


don Edition.     In  one  very  handsome  octavo  volume,  of  700  pages,  with  about  300  illustra- 
tions.    Cloth,  $4  00;  lenther,  $5  00.     (Just  Issued.) 
It  has  been  the  author's  endeavor  to  produce  a  Treatise  on  Chemistry  sufficiently  comprehen- 
sive for  those  studying  the  science  as  a  branch  of  general  education,  and  one  which  a  student 
may  age  with  advantage  in  pursuing  hischemical  studies  atone  of  the  colleges  or  medical  schools. 
The  special  attention  devoted  to  Metallurgy  and  some  other  branches  of  Applied  Chemistry  renders 
the  work  especially  useful  to  those  who  are  being  educated  for  employment  in  manufacture. 


We  have  iu  (his  work  a  complete  and  most  excel- 
lent  text-book  for  the  u-e  of  schools.  nod  can  heart 
ity  recommend  it  as  each.— .Boston  Jferf.  and  Sura, 
fnnrn..  May  28.  1874. 

The  shore  is  (ne  title  of  a  work  which  we  can  most 
conscientiously  recommend  to  students  ofchemistry 
t  is  as  easy  as  a  work  on  chemistry  could  be  made, 
it  the  same  lime  that  it  presents  H  full  account  of  that 
science  as  it  now  stands.  We  have  spokeu  of  the 
work  as  admirably  adapted  to  the  wants  of  students  ; 
It  is  unite  as  well  suited  to  the  requirements  of  prac- 


titioners who  wish  to  re  view  their  chemistry,  or  have 
occasion  to  refresh  their  memories  on  any  point  re- 
lating to  it.  In  a  word,  it  is  H  hook  to  be  read  by  all 
who  wish  to  know  what  is  the  chemistry  of  the  pre- 
sent day. — American  Practitiniier,Kov.  1673. 

Prof.  Bloxara  possesaespre-eminently  the  ineslima- 
hle  sifi  of  perspicuity.  It  is  »  pleasure  to  read  hi* 
hooks,  for  he.  i*  capable  of  making  very  plain  what 
other  authors  frequently  have  left  very  obscure. — 
Va.  Clinical  Record,  Nov.  1S73. 


rtLO  WES  (FRANK),  D.Sc.,  LJ,.,,^,,,. 

Senior  Science- Matter  fit  the  High  Schnal ,  yewcastle-nvder  Lyme,  etc. 

AN  ELEMENTARY  TREATISE  ON  PRACTIC  A  L  CHEMISTRY 

AND    QUALITATIVE  INORGANIC    ANALYSIS.     Specially  pdapted  for  Us*  in  the 
Laboratories   of  Schools  and  Colleges  and  by  Beginners.     From  the  Second  and  Revised 
English  Edition,  with  about  fifty  illustrations  on  wood.      In  one  v«ry  handsome  royal 
12mo.  volume  of  372  pages:  cloth.  $t  50.     (Notr  Ready.) 
The  methods  are  modern,  and  the  present  approv- 


system  of  nomenclature  and  notation  are  used 
*xelnsively— facts  which  especially  commend  the 
book  to  new  students  in  qualitative  analysis.- C/u"- 
ea.To  Mf,d.  Jonrn.  and  Examiner,  Oct.  1877. 

It  is  short,  concise,  and  eminently  practical.  We 
therefore  heartily  commend  it  to  stnden  s,  and  espe- 
cially to  those  who  are  obliged  to  dispense  with  a 
master.  Of  course  a  teacher  is  in  every  way  desi- 
rable,  bat  a  good  degree  of  technicil  skill  and  prac- 
tical knowledge  can  be  attained  with  no  other 
instructor  than  the  very  valuable  handhook  now 
under  coa.sidera.tion. — St  Loui*  Glin.  Record.  Occ. 
1877. 

The  work  ig  BO  writf  en  and  arranged  that  it  can  be 
comprehended  by  the  student  without  a  teacher,  aud 
tie  descriptions  and  directions  f.trthe  various  work 
are  so  simple,  aud  yet  eouci.se,  as  to  be  interesting 


and  intellig'ble.  The  work  is  unincnmbered  with 
theoretical  deductions,  dealing  wholly  with  the 
practical  matter,  which  it  is  the  aim  rf  (his  compre- 
hensive text-book  to  impart.  The  accuracy  of  the 
analytic*!  methods  are  vouched  fur  from  the  fact 
that  they  have  all  been  worked  through  by  the 
author  and  the  members  of  his  ciass,  from  the 
printed  text.  We  can  heartily  recommend  the  work 
to  the  student  of  chemistry  as  being  a  reliable  and 
comprehensive  oue. — Druggist^  Advertiser,  Oct. 
15,  1877. 

With  this  manual  before  him  the  advanced  stu- 
dent can  undertake  experiments  without  the  assist- 
ance of  the  professor.  The  aim  of  the  author  ha* 
been  to  make  it  as  simple  as  possible,  and  for  ttlit 
purpose  he  has  abandoned  many  technical  phrx.-os, 
and  substituted  therefor  simply  paraphrased  terms. 
—  Xttxhriile  3fed.  and  Surg.  Jonra.,  July,  1877. 


,  J/.Z?.,  Ph.D., 

Prvfensor  nf  Chemistry  in  the  John*  ffopkin*  University,  Baltimore. 

PRINCIPLES  OF  THEORETICAL  CHKMISTRY.  with  special  reference 

to  the  Constitution  of  Chemical  Compounds.     In  one  handsome  royal  I2ino.  vol.  of  over 
232  pages:  cloth,  $1  50.     (Just  I* sited.) 


For  such  study,  essential  forexactness  in  scientific 
thought.  Prof.  Remse.n's  book  supplier  Valuable  ma- 
terial. It  is  unif>rmly  clearaud  logical  The  author 
seldom  overstrains  a,  theory,  and  in  several  casns,  as 
for  instance,  in  his  remtrks  on  atomicity  (p.  81,  et 
f>eq.\  points  out  difficulties  which  are  too  often  over- 
looked. He  has  made  many  things  easy  of  compre- 
hension, which  are  generally  very  difficult,  and  al- 
together his  book  will  be  real  treasure  to  earnest 
students.  —  London  Land,  Aug.  IS77. 

This  volume  is  devoted  to  the  principlea  upon  which 
the  theoretical  structure  of  modern  i-hemi  try  is  hused. 
and  as  sur-h  it  is  a  very  valuable  addition  to  our  litera- 
ture, insomuch  a.«  it  discu-scs.  in  a  c'ear  and  corn1  re- 
hensive  manner,  the  various  laws  {jivernlnsr  chemical 


combination  and  decomposition,  and  the  various  theo- 
ries wlii.'h  have  hei-n  advanced  for  explaining  an- 
nounced f»ct«.  In  our  opinior.  the  work  will  prove  to 
b'  a  valuable  a:d  to  the  chemical  student  who  would 
familiarize  himsulf  with  the  ili-ories  nf  the  science  that 
h<ivf  led  to  in  tiy  important  discoveries. — Am.Journ. 
/  1'Jiarm..  June.  1877. 

Itisxn  adiiiii-ithle  presentation  of  the  leading  doc- 
trim  n  of  modem  chemistry  If  some  subjn 
briefly  treaty  I.  i'  i-  simply  because  so  little  is  really 
ki:»vvn  nlmur  them,  and  the  author  has  had  tin-  rme 
good  aense  not  to  luml»T  hi^  pxsies  with  inutrotitabla 
«pi-cul:itions  and  men-  ••  LMie-s.  s  at  the  truth  " — lintton 
Journ.  ofC/iem.,  May,  IS". 


TXTOHLBR  AND  FITTIG 

OUTLINES  OP  ORGANIC  CHEMISTRY. 


Translntod   with    Ad- 


ditions from  the  Eighth  German  Edition.  By  IRA  REMSKX,  M.D-,  Ph.D.,  Professor  of 
Chemistry  and  Physics  in  Williams  College,  Mass.  In  one  handsome  volume,  royal  12uio. 
of  550  pp.,  cloth.  $3. 

As  the  numerous  editions  of  the  original  attest,  this  work  is  the  leading  test-book  and  standard 
authority  throughout  Germany  on  its  important  and  intricate  subject — a  position  won  for  it  by 
the  clearness  and  conciseness  which  are  its  distinguishing  characteristics.  The  translation  has 
been  executed  with  the  approbation  of  Profs.  Wrihler  and  Fittig,  and  numerous  additions  and 
alterations  have  been  introduced,  BO  as  to  render  it  in  every  respect  on  a  level  with  the  most 
advanced  condition  of  the  science. 


12        HENRY  0.  LBA'S  PUBLICATIONS — (Mat.  Med.and  Therapeutics). 


PARRISH  (ED  WARD), 

Late  Professor  of  Materiel  Medica  in  the  Philadelphia  CoUege  o/ Pharmacy. 

A  TREATISE  ON  PHARMACY.    Designed  as  a  Text-Book  for  the 

Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.  With  many  Formulae  ana 
Prescriptions.  Fourth  Edition,  thoroughly  revised,  by  THOMAS  S.  WIBOA.ND.  In  one 
handsome  octavo  volume  of  977  pages,  with  280  illustrations;  cloth,  $5  50;  leather,  $6  Ml. 
(Lately  Issued.) 

The  delay  in  the  appearance  of  the  new  U.  S.  Pharmacopoeia,  and  the  sudden  death  of  the  au- 
thor, have  postponed  the  preparation  of  this  new  edition  beyond  the  period  expected.  The  notes 
and  memoranda  left  by  Mr.  Parriab  hare  been  placed  in  the  hands  of  the  editor,  Mr.  Wiegand, 
who  Has  labored  assiduously  to  embody  in  the  work  all  the  improvements  of  pharmaceutical  sci- 
ence which  have  been  introduced  during  be  last  ten  years.  It  is  therefore  hoped  that  the  new 
edition  will  fully  maintain  the  reputation  which  the  volume  has  heretofore  enjoyed  as  a  standard 
text-book  and  work  of  reference  for  all  engaged  in  the  preparation  and  dispensing  of  medicines. 

Of  I>r.  Parrish's  great  work  on  pharmacy  It  only  an  honored  place  on  our  owu  bookshelves. — Dublin 

remains  to  be  said  thai  the  editor  has  accomplished  Jfeit.  Prens  ami  Circular,  Aug.  12,  I>7  J. 

bi»  work  so  well  as  to  maintain   in  this  fourth  edi-  We  expre88ed  our  opinion  of  a  furiuer  edition  i. 

tion,  the  high  standard  of  excellence  which  it  had  terms  of  Qualified  praise,  and  we  are  in  >o  »oo4 

attained  in  previous  editions,  under  the  editorship  of  ,o  delrae,  fr<>m  ,na,  ..piuion  in  rflerenee  to  the  pre- 

Its  accomplished  anthor     This  ban  not  been  aeconr  ^^  ^5,^,,,,  tllfi  pre,x,ration  of  which  has  fallen  into 

pllshedwJthont  much  labor,  and  many  additions  and  competent  hands.  It  is  a  book  with  which  no  pbarma- 

lmproveraenti<,involvingchaDgesin  the  arrangement  e}Hl  ean  dispense,  and  from  which  uo  physician  can 

of  the  several  part*  of  the  work,  and  the  addition  of  fai,  to  deriTe  mnch  jnrorn>a,5on  ()f  Tli)ue  ,o  him  j, 

much  new  matter.     With  the  modifications  thus  ei-  prHctiee._ Pacific  Jftd  andSurg.Jvun.,  June, '74. 
fectfd  it  constitutes,  as  now  presented,  a  compendium 

of  the  science  and  art  indispensable  to  the  pharma-  With  these  few  remarks  we  heartily  commend  th« 

cist,  and  of  the  utmost  value  to  every  practitioner  work,  and  have  no  doubt  that  it  will  maintain  its 

of  medicine  desirous  of  familiarizing  himself  with  old  reputation  as  a  text-book  for  the  student,  aud  a 

the  pharmaceutical  preparation  of  the  article*  which  work  of  reference  for  the  more  experienced  pbysi- 

h  P  prescribes  for  his  patients.— Chicago  Uttd.Journ.,  ci»n   and   pharmacist .—  Chicago   lied.   Kzttmhter, 

July,  1874.  June  1J,  1874. 

The  work  Is  eminently  practical,  and  hag  the  rare  I  Perhaps  one,  if  not  the  most  important  book  npo» 
merit  of  being  readable  and  interesting,  while  it  pre-  pharmacy  which  has  appeared  iu  the  English  laa- 
ger ves  a  strict  ly  scieniificcharaeter.  The  whole  work  gunge  has  emanated  from  the  transatlantic  press, 
reflects  the  greatest  credit  on  author,  editor,  and  pub-  "  Parrisb's  Pharmacy"  is  a  well-knowu  work  on  thii 
Usher  I  twill  convey  some  idea  of  the  liberality  which  side  of  thewater.and  the  fact  shows  us  that  a  really 
has  been  bestowed  upon  itsprodnction  when  we  meu-  useful  work  never  becomes  merely  local  in  its  fame, 
tion  thatthereare  nolessihan  280carefully  executed  Thanks  to  the  judicious  editing  of  Mr.  Wiegaud,  the 
illustrations.  In  conclusion,  we  heartily  recommend  posthumous  edition  of  "Parrish"  has  been  saved  to 
the  work,  not  only  to  pharmacists,  but  also  to  the  the  public  with  all  the  mature  experience  of  its  au- 
multitnde  of  medical  practitioners  who  are  obliged  thor.  an<l  perhaps  none  the  worse  for  a  dash  of  n«w 
to  compound  their  own  medicines.  It  will  ever  hold  [  blood. — Loud.  Vhurm.  Journal,  Oct.  17,  1874. 


QTJLLE  (ALFRED),  M.D., 

&  Professor  of  Theory  and  Practice  of  Medicine  in  the  University  of  Penna. 

THERAPEUTICS  AND  MATERIA  MEDICA;  a  Systematic  Treatise 

on  the  Action  and  Uses  of  Medicinal  Agents,  including  their  Description  and  History. 

Fourth  edition,  revised  and  enlarged.    In  twolarge  and  handsome  8vo.  vols.  of  about  200* 

pages.     Cloth,  $10;  leather,  $12.     (Lately  Issued.) 

The  care  bestowed  by  the  author  on  the  revision  of  this  edition  has  kept  the  work  out  of  the 
market  for  nearly  two  years,  and  has  increased  its  size  about  two  hundred  and  fifty  pages.  Not 
withstanding  this  enlargement,  the  price  has  been  kept  at  the  former  very  moderate  rate. 

It  is  unnecessary  to  do  mnch  more  than  to  an-  of  the  present  edition,  a  whole  cyclopedia  of  thera- 

aonnee  the  appearance  of  the  fourth  edkion  of  thia  peuties. — Chicago  Xtdienl  Journal,  Keb.  1  ~ 

welt  known  aud  excollenl  work.— Brit,  and  For.  Thp  magnjflVe,,,  work  of  Professor  Stille  is  knovra 

Med.-Chir.  K«view,Ot  wherever  the  English  language  is  read,  aud  the  art 

For  all  wrho  desire  a  complete  work  on  therapeutics  of  medicine  cultivated;  kuowu  so  well  that  no  euco- 

and  materia  medlca  for  reference,  in  case*  involving  inium  of  ours  could  brighten  its  fame,  aud  uo  nnfa- 

medico-legal  questions,  as  well  as  for  information  vorable  criticism  conld  taruish  it-irt>pulation.— Phil- 

eoncerning  remedial  agents,  Dr.  Still^'s  is  "par  rx-  atielphta  Mtd.  Times,  Dec.  12,  IS74. 

cellf.nce"  the  work.    The  work  being  out  of  print,  by  The  rapid  exhaustion  of  three  editions  and  the  uni- 

IheexhMnstiouofforraereditions.theanthorhaslaid  Ter»al  favor  with  which  the  work  has  been  r- 

the   profession   under  renewed   obligations,  by  the  by  the  medical  profo^lon,  are  sufficient  proof  of  its 

earefnl  revigion,  important  additions,  and  timely  re-  excellence  as  a  repertory  of  practical  and  mefnl  in- 

;  a  work   not  exactly  supplemented   by  any  furioation  for  tbe  physician.    The  edition  before  us 

other  in  the  hnglUh  language,  if  in  any  language,  fully  sustains  this  verdict, asthe  work  has  been  care- 

The  mechanical  execution  handsomely  sustains  tue  ful)y  ^^^^  HIld  in  80me  j>«rtiong  rewritten,  briug- 

well-known  skill  and  good  taste  of  tho  publisher—  in/?  it  „„  ,„  the  pre^en,  tinle  j,y  the  admission  of 

St.  Louis  Jfett.  and  Sura.  Journal,  Dec  1874.  chloral  and  croton  chloral,  nitrite  of  ainyl,  bichl.,- 

The  prominent  feature  of  Dr.  StllK  s  great  work  ride  of  methylene,  methylic  ether,  lithium  cook- 
ig  sound  good  sense.  It  is  lexrned.  but  it«  learning  pounds,  gelseminnm,  and  other  reuueilits. — At*. 
In  of  inferior  value  compared  with  the  discriminating  Journ.  of  Pharmacy,  Feb.  l->7.~>. 
judgment  which  is  shown  by  its  anthor  inthedis-  We  can  hardly  admit  that  it  bas  a  rival  in  the 
cussion  of  his  subjects,  aud  which  renders  it  a  trust-  mnltitnde  of  it«  citation"  and  the  fulness  of  Its  re- 
worthy  guide  iu  the  sick-room.— Am.  Practitioner,  gearoh  lntl)  clinical  histories,  and  we  must  assign  it 
Jan.  1875.  a  piac*  in  the  physician's  library;  not,  indfed,  as 

From  the  publication  of  the  first  edition  "StlH^'s  fully  ri'|>r>--.'iiiin^  th>-  prcst-ut  >iate  of  knowledge  iu 

Therapeutics"  has  been  one  of  the  classics;  its  ab-  pharmacodynamics,  but  as  by  far  the  most  complete 

eence   from    our  libraries  would   create   a  vacuum  treatise  upon   the  clinical  and  practical  side  of  the 

which  conld  be  filled  by  no  other  work  in  the  Ian-  question. — Sontun  Mtd.  und.  Surg.  Jvurnul,  Uov.c, 

guage,  and  its  presence  supplies,  in  the  two  volume*  1874. 


HENRY  C.  LEA'S  PUBLICATIONS— (Mat.  Med.  and  Therapeutics).       1 3 


UTILLE  (ALFRED).  M.I),  LL.D.,  and    \fAlSCH  (JOHN  M.}.  Ph.D., 

Prv    !'f.Tflffr"ry'<"f'i  Practice  of  Clinical  ±1±        Pro/,  of  Mat.  ifrA.  «,,,1  R,,t   in  PMla. 

Med.  in  UK.IV.  of  Pa.  c,tn.  Pharmacy.  S-.oj.  t;  tht.  American 

Plinrmace.ut icrtl  X  .we ii'.t ion 

THE  NATIONAL  DISPENSATORY:  Embracing  the  Chemistry,  Botany, 

Materia  Medina,    Pharmacy,   Pharmacodynainics,  and  Therapeutics  of  the  Pharmaco- 
poeias of  the  United  St.ites  and  Great  Britain.     For  the  Use  of  Physician?  and  Pharma- 
ceutists.    In  one  hanlsome  octavo  volume,  with  numerous  illustrations.     (In  Press.) 
The  want  has  long  been  felt  and  expressed  of  a  work  which,  within  a  moderate  compass, 
should  give  to  the  physician  and  pharmaceutist  an  authoritative  exposition  of  the  Pharmaco- 
poeias from  the  existing  standpoint  of  medic  il  and  pharm  iceutical  science.     For  several  years 
the  authors  have  been  earnestly  engaged  in  the  preparation  of  the  present  volume,  with  the 
hope  of  satisfying  this  w:\nt,  and  their  labors  are  now  sufficiently  advanced  to  enable  the  pub- 
lisher to  promise  its  appearance  during  the,  coming  season.     Their  distinguished  reputation  in 
their  respective  departments  is  a  guarantee  that  the  work  will  fulfil  all  reasonable  expectation  as 
a  guiile  in  the  selection,  compounding,  dispensing,  and  medicinal  uses  of  drugs,  complete  in  all 
respects,  while  convenient  in  size,  and  carefully  divested  of  all  unnecessary  and  obsolete  (tatter. 

J?ARQ.DHARSON  (RODKRT).  J/./>.. 

r.trturnr  rm  3Intr.rin  Mniiiffr  fit  St.  Mary'*  Hospital  Medical  School. 

A  GUIDE  TO  THERAPEUTICS.     Edited,  with  Additions,  embracing 

the  U.  S.  Pharmacopoeia.     By  FKANK  WOODBUHV,  M.D.      In  one  neat  volume,  rojal 
12mo.  volume  of  over  400  pages  :  cloth,  $2.     (Now  Ready.) 

The  object  of  the  author  has  been  to  present  in  a  compact  and  compendious  form  the  the- 
rapeutics of  the  Materia  Medica,  unincumbered  by  botanical  and  pharmaceutical  details.  The 
volume  is  thus  emphatically  a  work  for  the  medical  student,  to  aid  in  hij  acquiring  a  clear  and 
connected  view  of  the  subjtct  in  its  most  modern  aspects;  and  for  the  busy  practitioner  who 
may  wish  to  refresh  his  meinorv.  Under  each  article,  in  parallel  columns,  are  given  its  phy- 
siological and  therapeutical  actions,  thus  enabling  the  reader  to  take  in  at  a  glance  the  essential 
facts  with  respect  to  each  remedy,  and  numerous  formulae  are  given  as  examples  of  their  prac- 
tical use.  Considerable  additions  have  been  introduced  by  Dr.  Woodbury,  who  has  made 
numerous  changes  to  oda.pt  the  work  to  the  wants  of  the  American  student,  introducing  all  the 
preparations  of  the  U.  S.  Pharmacopoeia,  and  many  of  the  newer  remedies. 

This  little  volume  is  an  earnest  effort  to  advance  manner,  that  it  deserves  cnreful  study  by  every  stu- 
the  i«)t<>ie.sts  of  intelligent  therapeutics.  In  a  mode-  dfut  and  young  practitioner. —  Cincinnati  Clinic, 
rate  compass  we  find  'he established  facts  concerning  Jan.  12,  1S7S. 

th«  physK,l<,gical  and  therapeutical  actions  of  reme-  Many  peraon8  who  learned  thcrapentic.s  before 
,S"  ™*™ft**v™to****™t*  °f  threat  remedies  the  physiological  action  of  remedies  was  taught  to 
ia  health  and  disease  are  pre-eatcd  in  parallel  col-  KtU(lents  find  it  difficalt  to  discorer  tue  bearing  of 
un.as.  This  arrangement  impresses  ns  very  favor-  ,,hy8iolo«ical  action  on  therapeutic  employnfent 
Hbiy,  as  both  convenient  and  etiolated  to  stamp  from  ordinary  text-books.  Dr.  Farquharsou  hasmost 
the  facts  upon  the  memory.  We  d  J  not  know  of  an  iDgeniously  shown  it  by  printing  the  two  in  parallel 
equal  number  of  pages  in  one  work  that  con  ains  for  coiurans  and  corresponding  paragraphs,  so  that,  by 
the  n<*ds  «f  ttM  student  anything  near  as  valuable  running  the  eye  down  the  left-hand  side  of  a  page  we 
an  account  ot  these  subsUnces.  We  can  cordially  et  the  physiological  actions  of  a  drug,  and  on  the 
commend  this  work  to  the  medical  stnd-nta*-  the  best  rigl)t-hand  rhe  therapeutical  uses,  while,  bv  running 
introduction  to  th«  study  of  larger  and  more  elabo-  it  stl.aiif|)t  acrO88  tne  pagt)  w<>  at  once  perceive  the 
rated  treaties  —Detroit  Lancet,  Jan.  18/S.  j  re|H,i,,Us  of  the  one  to  the  other.  On  this  account,  the 

An  excellent  feature  of  r>r  Farquharsou's  Guide,  work  is  likely  to  be  useful,  not  only  to  students  pre- 
and  oue  which  trill  commend  it  to  all  earnest  stu-  \  piringfor  their  examinations,  hut  to  those  medical 
dents,  is  the  arrangement,  in  tabular  form,  of  the  va-  '  men,  also,  who  are  well  acquainted  with  larger 
rious  officinal  preparations  and  their  dose,  so  that  '•  books  on  the  same  subject,  but  experience  the  diffl- 
they  may  be  readily  committed  to  memory  This  ctilty,  already  mentioned,  of  seeing  the  relations 
handbook  is  so  well  arranged,  aud  presents  the  well  between  the  actions  and  use  of  remedies.  —  The 
established  facts  of  therapeutics  in  so  impressive  a  Lnnd<in  Praclitiontr,  January,  ISIS. 


Q.RIFFITH  (ROBERT  E.},  M.D. 


A  UNIVERSAL  FORMULARY,  Containing  the  Methods  of  Prepar- 
ing and  Administering  Officinal  and  other  Medicines.    The  whole  adapted  to  Physiciars  and 
Pharmaceutists.     Third  edition,  thoroughly  revised,  with  numerous  additions,  bj  JOHN  M. 
MAISCH,  Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy.  In  one  large 
and  handsome  octavo  volume  of  about  800  pp..  <•!.,  $4  50;  leather,  $5  50.    (Lately  Issxni  ) 
As    a  comparative  view  of  the  United  States,  the    British,  the  German,  and    the    French 
Pharmacopoeias,  together  with  an  immense  amount  of  unofficinal  formulas,  it  affords  to  the  prac- 
titioner and  pharmaceutist  an  aid  in  their  daily  avocations  not  to  be  found  elsewhere,  while  three 
indexes,  one  of  "Diseases  and  their  Remedies,"  one  of  Pharmaceutical  Names,  and  a  Ueneral 
Index,  afford  an  easy  key  to  the  alphabetical  arrangement  adopted  in  the  text. 


To  the  druggist  a  good  formulary  is  simply  iudis- 
peawible.  and  perhaps  no  formulary  has  been  more 
extensively  used  than  the  well-kuown  work  before 
as.  Many  physicians  have  to  officiate,  also,  as  drug- 
gists. This  is  true  especially  of  the  country  physi- 
cian, and  a  work  which  shall  teach  him  the  means 
by  which  to  administer  or  combine  his  remedies  in 
the  most  efficacious  and  pleasant  manner,  will  al- 
ways hold  its  place  upon  his  shelf.  A  formulary  of 
tht«  kind  is  of  benefit  also  to  the  city  ohysiciiin  in 
largest  practice. — Cincinnati  Clinic,  Feb.  21,  187i. 


A  more  complete  formulary  than  it  is  in  its  pres- 
ent form  the  pharmacist  or  phjr»lelaa  could  hardly 
desire  To  the  first  some  such  work  is  iudi-i>eu>a- 
ble,  and  it  is  hardly  It^s  essential  to  th«  practition.-r 
who  compounds  his  own  medicines.  Much  of  what 
is  contained  in  the  introduction  might  to  be  e»m- 
mitted  to  memory  by  every  student  of  medicine. 
As  a  help  to  phy.-U'htus  it  will  be  found  Invaluable 
and  doubtless  vrill  make  its  way  into  lilir.iries  not 
already  supplied  with  a  sU'nlard  work  of  the  kind  . 
—  The  American  Practitioner,  Louisville,  July,  '74. 


HENRY  C.  LEA'S  PUBLICATIONS — (Pathology,  &c.}. 


(V.),  AND  ftANVIER  (A.). 

v         Pr»f.  in  the  Faculty  of  Iff  tl  ,  Hirix.  Prof  in  the  College  of  Frnur, . 

MANUAL  OF    PATHOLOGICAL    HISTOLOGY.     Translate.!,  witli 

Notes  nnd  Additions,  by  E.  0.  bBAKr.spKAKE,  M.D  ,  Ptithnlogi^t  and  Ophthalmic  Surgeon 
to  Pbilnda  Hospitnl,  Lecturer  on  Refrrciion  and  Operntive  Ophthalmic  Surgery  in  I'niv. 
of  Penna.  In  one  very  handsome  octavo  volume  of  about  600  pnges,  with  over  300  illus- 
trations (Preparing.) 

So  much  hns  been  done  of  lute  years  in  the  elueidntion  of  pathology  by  means  of  the  micro- 
Kcope,  and  this  subject  now  occupies  so  prominenta  position  ns  one  of  the  most  important  l>r:uiche.« 
of  me'dical  science,  that  the  American  profession  cannot  fail  to  welcome  a  translation  of  the  pre- 
sent work,  which,  through  its  own  merits  nnd  through  the  well-known  reputation  of  its  distin- 
guished authors,  is  regarded  in  Europe  as  the  standard  text-book  and  work  of  reference  in  its 
department  Such  investigations  and  discoveries  as  hpve  been  made  since  its  nppe;irnnce  will  be 
introduced  by  the  translator,  nnd  the  work  is  confidently  expected  to  assume  in  this  country  the 
same  position  which  has  been  so  universally  accorded  to  it  abroad. 

JfENWlCK  (SAMUEL),  M.D., 

•*•  Asftftnnt  Physician  to  the  London  Hospital. 

THE  STUDENT'S  GUIDE  TO  MEDICAL  DIAGNOSIS.    From  the 

Third  Revised  and  Enlarged  English  Edition.  With  eighty-four  illustrations  on  wood. 
In  one  very  handsome  volume,  royal  12mo.,  cloth,  $2  25.  (Just  Issued  ) 


Of  the  in  uy  guide-books  on  medical  diagnosis, 
claimed  to  be  written  for  the  special  instruction  of 
students,  this,  is  the  bent.  The  anthor  i«  evidently  » 
well-read  and  accomplished  physician. and  he  knows 
how  to  teach  practical  medicine.  The  charm  of  sim- 
plicity is  not  the  least  int  resting  feature  in  the  man- 
ner in  which  Dr.  Fenwickcunveys instruction.  There 
are  few  books  of  this  size  on  practical  medicine  that 
contain  KO  ranch  and  convey  it  so  well  as  the  volume 
before  as  I'  is  a  book  we  can  sincerely  recommend 
to  the  student  f  >r  direct  instruction,  and  to  the  prac- 


titioner as  a  ready  and  useful  aid  to  hr»  memory. — 
Am.  Journ.  of  Syphilography,  Jan.  1874. 

It  covers  the  ground  of  medical  diagnosis  in  a  con- 
cise, practical  manner,  well  calculated  to  astittt  |ii« 
Htndeut  in  forming  a  correct,  thorough,  and  system- 
atic method  of  examination  aud  diagnosis  of  disei.-e. 
The  illustrations  are  numerous,  and  finely  executed. 
Those  illustrative  of  the  microscopic  appearsuce  of 
morbid  tissue,  &e.,  are  especially  clear  and  distinct. 
— Vhictigo  Xed.  Examiner,  Mov.  U7S. 


riREEN  (T.  HENRY),  M.D., 

Lecturer  on  Pathology  and  Morbid  Anatomy  at  Oharing-Oroft  Hospital  Medical  School. 

PATHOLOGY  AND  MORBID  ANATOMY.   Second  American, from 

the  Third  and  Enlarged  English  Edition      With  numerous  illustrations  on  wood.     In  one 
very  handsome  octavo  volume  of  over  300  pages,  cloth    $2  75      (Just  Issued.) 


Th.>se  not  acquainted  with  this  text  book  ought  to 
be.  We  have  always  thought  that  for  Ihn  average 
doctor  this  work  wa^  much  more  nsef  ill  than  the  larger 
irealixe-i.  liitoit  is  condensed  such  knuwl  dgeto^Hin 
which,  elsewhere,  would  require  great  labor  ami 
wide  reading.  For  student*  and  practitioners  full 
of  cares,  it  i«  particularly  v  ilua^le.  In  this  edition 
the  goneral  h'gh  chancterof  the  work  is  maintained, 
the  newcolH  are  fully  np  to  the  standard  of  those 
ijsfil  before,  which  w-°re  excellent,  the  execution  of 
the  work  at  the  hands  of  the  publisher  is  f.mliles* 
—Ohicngo  Mul  Journ  attti  Krnm.,  Feb  1877. 

Altogether.  thislR  the  best  short  manual  of  morbid 
anatotnyin  the  English  language,  aud  we  regret  that 


onr  space  and  the  character  of  our  contents  forbids  * 
more  extended  notice  The  arrangement  and  choice 
ofsnbjects,  the  olearness  and  romparxlire  thonmgh- 
ues«  of  its  statements  make  it  very  satisfactory  W<i 
are  espacially  ]i)pa««d  with  lh»  appearance  of  the 
wood  cots,  most  of  them  made  for  this  work  after  its 
author's  own  sfxrion"  and  drawings.  We  can  only 
repeat  what  we  htive  said  before,  that  we  know  of 
nothing  in  th»  w*ty  of  a  brief  MI  mm  I.  superior  to  H 
>B°th«|iOKH*n language.  It  may  he  safely  anrt  hen rti!y 
ci  >  in  mended  t«»  snideols,  especially  of  morhtd  ana- 
lomy.— Joiim.  of  tfervitis  an't  Mental  Hiftatt,  Oct. 
1S7B. 


D 


AVIS  (NATHAN  £). 

Prof,  of  Principfe*  nnd  PraHice  of  Mffiicinr.,  fie.,  in  dhir-ngo  3Tfd.  College. 

CLINICAL  LECTURES  OX  VARIOUS   IMPORTANT   DISEASES; 

being  a  collection  of  the  Clinical  Lectures  delivered  in  the  Medical  Wards  of  Mercy  Hoc- 
pita),  Chicago.  Edited  by  FRANK  H.  DAVIS,  M  D.  Second  edition,  enlarged.  In  one 
handsome  royal  12mo.  volume.  Cloth,  $1  75.  (Lately  Issued.) 

tical  Relations.   ID  two  large  and  handsome  octavo 
volnroes  of  nearly  1500  pages,  cloth.     $7  00. 

HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TIONS. )  vol  Svo.,  pp.  SftO,  cloth.  $S  .*iO. 

BARLOW'S  MANUAL  OP  TBE  PRACTICE  O» 
XEDICIKB.  With  Addition  by  D.  F.  ConBlE, 
M  r>  1  TO!  Svo..  pr-  0<VI  cloth 

TODD'SCLWICAL  LKCTtTRE.S  ON  CERTAIN  ACUTB 
DIXKASKB.  In  oae  neat  octavo  volume,  of  S2n  p»ge». 
cloth.  *2  /in 


WHATTOOBSBRVEATTHBBBDSIDKANDAFTUK 
DHATH  in  MEDICAL  CASKS.  Krbm  the  se;-onl  Lon- 
don edition.  1  vol  -oyal  12m»  ,  cloth.  *M>o 

OHHISTISON'B  DISPRN8ATOKY.  With  copious  ad 
Hltlou*  "tsd  5'3  l»rr»  wno<«-on«'r»»»n«'s  Uy  R 
B  u,KsrBLn<Jair?iTH,  M.  D.  On«  vol  Svo.,  pp.  1001  > 
cloth.  *4  00. 

CARPENTBR'8  PRIKB  BS8AT  OH  THK  D8B  O> 
ALCOHOLIC  LIODOEU  m  HEALIH  AND  PISKAS.B.  Xev 
edition,  with  a  Preface  by  D.  F.  OO*DIE.  M  D.,  anr 
explanationaof  seientiAc  word«.  In  one  neat  12nu  . 
volnine,  pp.  17S,  cloth.  60  cents 

OLDGB'8  ATLAS  OF  PATHOLOGICAL  HISTOLOGY 
Translated,  with  Notes  and  Additions,  by  JO-JRPH 
LBIDT,  M.  D.  In  one  volume,  very  large  Imperial 
quarto,  with  320  copper-plate  figures,  plain  and 
colored,  cloth.  *l  OO. 

L4.  ROOHS  0V  TELLOW  FEVER,  considered  in  lt» 
Historical,  Pathological,  Etiological,  andTherapeo- 


srrRf?Ks-s  ixTRonrmox  TO  TFIE  .srrnv  OF 

(T.IMCAT,  MEHiriXE.  Being  a  Gnu?"  to  the  In- 
vestigation of  PispHse.  In  OPP  handsome  7-ino. 
volume,  cloth,  «»J  2."i  (Lntrhf  twerf.) 
STORES'  LErTt'KKS  ON  FEVER  Fdited  by  Jonx 
WIM.'AM  MI>ORK,  M.  D..  Assistant  Physician  to  the 
Cork  S're.'t  Fere'-  Hosr.jtal.  In  one  neat  Svo. 
volume,  cloth,  $2  00.  (Juxt  Jgx-utd  ) 


.  LEA'S  PUBLICATIONS — (Practice  of 


15 


FLINT  (AUSTIN],  M.D., 

*  Professor  of  the.  Principle*  and  Practice  of  Hfedicine  in  Bellewte  Mvd.  Collage,  K.  Y 

A   TREATISE    ON    THE    PRINCIPLES    AND    PRACTICE    OF 

MEDICINE  ;   designed  for  the  use  of  Students  and  Practitioners  of  Medicine.     Fourth 

edition,  revised  and  enlarged.    In  one  large  and  closely  printed  octavo  volume  of  about  1100 

pp.  ;  cloth,  $6  00  ;  or  strongly  bound  in  leather,  with  raised  bands,  $7  00.    (lately  Issued.) 

By  common  consent  of  the  English  and  American  medical  press,  this  work  has  been  assigned 

lo  the  highest  position  as  a  complete  and  compendionAext-book  on  the  most  advanced  condition 

of  medical  scienc*.     At  the  very  moderate  price  at  which  "it  is  offered  it  will  be  found  one  of  the 

sheapest  volumes  now  before  the  profession. 

This  excellent  treatise  on  medicine  has  acquired  ]  dentsand  abook  nf  ready  reference  for  practitioners, 
tor  itself  in  the  rr«ited  States  a  reputation  similart<>  ',  The  force  of  its  logic,  its  simple  and  practical  teach- 
th;U  enjoyed  in  England  by  the  admirable  lectures  ings,  have  left  it  without  a  rival  in  the  field — N.  ¥. 
of  Sir  Thomas  Watson.  £t'may  not  possess  the,  saiae  ;  Med  Record,  Sept  15,  1874. 

charm  of  style,  but  it  h-is  like  solidity,  the  fruit  of  FHnt'sPracticeof  Medicine  bus  become  so  fixed  in 
long  and  patient  observation,  and  presents  kindred  :  its  position  an  an  American  text  book  that  little  need 
moderation  and  eclecticism.  We  have  referred  to  ,le  8aid  beyond  the  announcement  of  a  n«w edition, 
many  of  the  mostimportantchapters.  and  find  the r<?-  It  may  however,  he  proper  to  say  that  the  author 
vision  spoken  of  in  the  preface  is  a  gennise  one,  and  has  improved  the  occasion  to  introduce  the  Utost 
that  the  author  has  very  fairly  brought  up  his  matter  contributions  of  medical  literature  together  with  the 
tothelevel<.ftheVnowledgeof  the  present  nay.  The  results  of  bis  owa  continued  clinical  observations, 
work  hastMsgreatrecommendation, that  !tl«In  one  Xot  sY>  extended  as  many  of  the  standard  works  oa 
volume,  aud  therefore  will  not  *«  so  terrifying  to  tlie  ;  prdelicp.  it  still  is  sufficiently  complete  for  all  ordi- 
student  as  the  bulky  volumes  which  several  of  our  narv  reference  and  we  do  not  know  of  a  tnorecon- 
Enerlish  text-books  of  medicine  have  developed  into,  venient  work  for  the  busy  eaneral  practitioner. — 
—  British  rind  Foreign  Sfed.-Chir.  Ren.,  Jan.  187t.  i  Citwinna.ti  Lnnr.f.t  a-nd  O'ttervf.r,  Jane,  1878. 

Itisof  eanrsettnoececKary  teintrodnoe.or  enlogire  j  Prof.  Flint,  in  the  fourth  edition  of  his  great  work, 
this  now  standard  treatise  All  the  college*  worn-  has  performed  H  labor  reflecting  much  credit  upon 
mend  it  as  a  text-book,  and  there  are  few  lihraries  .  h'm  self,  a  ndeonferringa  lasting  benefit  upon  the  pro- 
in  which  on«  of  its  editions  is  not  to  be  fonnd.  The  ,  fession.  The  whole  work  showsevidenc*  of  thorough 
present  edition  h-a«  been  enliira^d  and  revised  tobring  revi-ion,  so  that  it  appears  like  a  new  book  wiitten 
it  up  to  theanthor's  present  level  of  experipnce  and  expressly  for  the  times  For  theg«n«ral  practitioner 


reading     His  own  clinical  studies  and  the  latest  con- 


and  student  of  medicine.  w«  cannot  recommend  the 


triburiotis  to  medical  literature  'both  in  tnic  country  \  book  in  too  strong  terms  —A*.  1'  Mr.d.Joitr  .Sept  '73. 
and  in  Karope.  have  received  careful  attention,  so  jt  js^iTen  to  very  few  men  to  tread  in  the  steps  of 
that  some  portions  have  been  entirely  rewritten,  and  i  ^Hg|jo  Flint,  whos«  single  volume  ou  medicine, 
about  seventy  pages  of  n«w  matter  have  been  added  i  thmlg^,  hereaad  there  defective,  is  a  imsterpiece'of 


-•Qh.if.nyc,  M'd   Jovrn.,  June,  1873. 
Has  never  been  surpassed  «s  a  text-book  for  sta- 


Uicid  condensation  and  of  general  grasp  of  an  enor- 
mously wide  subject  — Lend.  Practitioner,  Dec.  '73. 


»F  THV  SAME  AUTHOR. 

ESSAYS    ON    CONSERVATIVE    MEDICINE    AND    KINDRED 

TOPICS.     In  one  very  handsome  royal  I2rao.  volume.    Cloth,  $  I  38.     (Just  1st  «td  ) 


fJARTSHORNE  (HENRY),  M.D., 

•£•*>•  Prt)/e«*or  of  Hgytene  in  tkt  University  of  Pen-mtvl******- 

ESSENTIALS  OF  THE   PRINCIPLES  AND  PRACTICE  OF  MED1- 

CiNE.     A  haady-book  for  Students  and  Praetition«r*.     Fourth  edition,  revised  and  im- 
proved.    With  about  one  hundred  illustrations.     In  on«  handsome  royal  12mo    volume, 
of  about  550  pages,  cloth,  $2  63;  half  bound,  $2  88.     (Lately  Ittned.) 
A«  a  haadboak,  which  clearly  sets  forth  tlieu^FW-  i  advances  in  medicine,  is  admirably  condoned,  and 


d  AIS  of  tliePttl-VCIPI.BS  A.VD  PRArTtCBflF  MBDIOI 

o  not  know  of  its  equal.—  Vn.  Hed.  Monthly 


yet  sufficiently  explicit  fur  all  the  purposes-intended, 
thus  maknie  it  by  fur  the  best  work  of  It*  diameter 


,      Ter  published.  —  Cincinnati  Minic,  Oct   24,  1CT4. 
As  a  brief,  condensed,  but  comprehensive  band-  I  c  . 

book,  it  cannot  be  improved  upoJ i.-CMnago  M*d   \   •  Without  d.-nbt  the  best  book .of  thejtlnd  publish. 


,  Nov.  J5,  1874 


The  w«rk  i«  bj  ought  fully  np  with  all  the  rwentf  Jnnrn -.  N<"-  l! 


i  in  the  English  languag«.—  St.  Lotii*  Mtfl.  <md  Snrg . 


_.T50AT  (THOMAS),  M.  D.,  &c. 
fr  LECTURES     ON     THE     PRINCIPLES    AND    PRACTICE 

PHYSIO.     Delivered  at  King's  College,  London.     A  new  American,  from  the  F 

vised  and  enlarged  English  edition.      Edited,  with  additions,  and  several  hundred  illiu tra- 

tioa«,byH.«i?HART8Bo*KB>l«.0.,Profe««or<ifHygi««i«th.^^«^y^P<«n«ylv8' 

nia.   In  two  large  and  haatUomeSro.  vole.  Cloth,  $966;  leather,  $11 

[t  is  a  subject  for  congratulation  and  for  thankful-  i 
ness  that  Sir  Ttnunas  Witson.  during  a  period  of  coin-  i 
parative  leisure,   after  a  long,  laborious,  and    most 
honorable  professional   career,  while  retaining  full 
possession  of  his  high  mental  faculties,  should  have 
employed  the  opportunity  to  submit  his  Lectures 
ai  more  thorough  revision  than  was  possible  during 
the  earlier  and   busier  period  of  his  life.    Carefully 
passi<ngin  review  som«  of  the  mosi  intricate  and  n 
portant  pathological  and  practical  questions,  there 
s«H«  of  his  clear  insight  aad  his  calm  jud.gmeut  a 
now  recorded  for  the  benefitof  mankind,  in  language 
which,  for  precision,  vigor,  and  classical  elegance,  ha* 


nrely  been  equalled,  and  never  surpassed  The  re- 
ritiioD  has  evi.lsntly  bees  most  carefully  done, and 
-.he  results  appearin  almosi  every  page  —Brit  M>d. 
Tov.rn  ,  Oct.  14,  1871. 

The  author's  rare  combination  of  great  scientific 
attainment*  couibined  with  wonderful  forensic  eio- 
nuence  has  exerted  extraordinary  Influence  over  the 
last  two  generations  of  physicians.  His  clinica  de- 
scriptions of  most  dUease.shave  nevei  been  equalled  : 
and  on  this  score  at  least  his  work  will  live  long 
in  the  future.  The  work  will  be  s-mght  by  ai 
appreciate  a  great  book.— Amer.  Journ.  uj  SfjMl- 


ography,  July,  1872. 


16 


HENRY  C.  LEA'S  PUBLICATIONS — (Practice  of  Mt  dicinc). 


r>RISTOWR  (JOHN  SYEIf),  M.D  ,  F.R.C.P., 

J-S  Pfiytiiciiin  and  Joint  Lecturer  on  ttedicinf,  fit.  Thoina*'*  H"*j'Hn1. 

A  MANUAL  ON  THE  PRACTICE  OF  MEDICINE.     E.lite.l,  with 

Additions,  by.  JAMES  II.  Ilu  CHINKON,  M.D.,  Physician  to  the  Penn.-i.  Hospital.     In  one 

handsome  octavo  volume  of  over  1100  pages:  cloth,  $5  50;  leather,  $6  50.    (Just  Ready.) 

In  the  effort  of  the  author  to  render  this  volume  a  complete  and  trustworthy  guide  for  the 

student  and  practitioner  he  has  covered  a  wider  field  than  is  customary  in  text-hooks  on  the 

Practice  of  Medicine,  and  has  sedulously  %ndeavored  to  present  each  sobjeet  in  the  light  of  the 

in  os  i  modern  developments  of  observation  and  treatment.    So  much  has  been  done  of  late  years  to 

enlarge  our  knowledge  of  disease  by  improved  methods  of  diagnosis,  and  so  many  new  ngencie* 

have  been  called  into  service  in  treatment,  that  n  condensed  and  compendious  work,  thoroughly 

on  a  level  with  the  advance  of  medical  science,  can  hardly  fail  to  prove  of  value  to  the  profV 


Dr.  Bris'owe  ha"  long  been  before  the  profession 
as  nn  able  thinker  acd  writer  on  professional  sul>- 
J.TI-.  Hi-  present  work  is  second  to  none  of  its 
kind,  the  part  on  diseases  of  the  nervous  system 
being,  perhaps,  the  most  deserving  of  praise.  It  is 
eminently  readable,  both  in  matter  and  print,  and 
fully  deserves  tbe  success  it  is  sure  to  obtain. — 
Bdin.  Jfed.  Journ.,  Oct.  1877. 

The  treatment  of  the  various  diseases i» admirably 
summed  np,  and  we  pronounce  l>r.  Brist-iwe's  boon 
to  be  eminently  practical  on  Ibis  subject.  A  fair 
space  is  given  to  the  dietetics  of  disea-e  and  we  are 
.Bind  th»t  this  subject  is  receiving  more  and  more 
attention  in  the  w  rks  on  medicine  We  give  the 
author  our  hearty  congratulations,  and  his  book  onr 
best  commendations  and  wish  it  all  success. — Lond. 
Med.  Time*  and  <J«z..Sept.  15,  1877. 

Anyone  who  wants  a  good,  clear,  condensed  work 
upon  Practice,  quite  np  witb  the  most  recent  viewsln 


practitioners  who  purchase  few  books  will  find  this 
:t  mof.t  opportune  pnbliciition,  because  to  many  top- 
ics not  usually  emb.-aetvl  in  H  work  on  practice  are 
adeqnaiely  handled.  Tbe  book  is  a  thoroughly  good 
one,  and  its  usefulness  to  American  readers  has  been 
increased  by  the  jmlijions  notes  of  the  Editor. — 
Ctncinnfiti  Clinic,  Jan  7,  J677. 

An  immense  amount  of  information  has  been  com- 
pressed into  this  volume.  Every  page  U character- 
ized by  the  utterances  of  a  thoughtful  man.  While 
we  could  wish  a  fuller  discussion  and  greater  detail 
in  relation  to  many  *nbjec;s,  we  are  constrained  to 
say  that,  what  lias  been  said  hae  been  well  *»id,and 
the  book  Is  a  lair  reflex  of  all  that  is  cert'i-inly 
known  on  tbe  subjects  considered. — Ohio  Mul.  Re- 
corder, Jan.  1877 

Upon  Ibe  whole,  we  know  of  no  work  which  we 
could  more  confidently  recommend  to  the  student  or 
tbe  practitioner,  intending  a  review  of  tbe  field  of 


pathology, will  find  this  a  mostvaluablework     The  j  ,heo^     and  pr^lUe<  tban   thin  book  of  Dr.   „... 
additions  made  by  Dr.  Hnichinson  are  appropriate  j  tow,,*     We  thus  commend  it,  because  the  vast  ar- 


and  useful,  and  so  well  done  that  we*ish  there  were 
more  of  them.—  Am.  P-actttianfr,  Feb.  1877. 

This  portly  volume  is  a  model  of  condensation. 
In'a  style  at  once  clear,  interesting, and  concise,  Dr. 
Bristowe  passes  in  review  every  conceivable  subject 


ray  of  facts  pertaining  totbe  practice  of  medit-ine,.,., 
it  i.-  lo.day,  are  here  presented  ably,  and  with  that 
method,  order, and  perspicuity  which,  in  all  depart- 
ments of  education,  di.-stingnlsh  the  lessons  of  an  ac- 
ceptable and  profitable  teacb»r  — Chicago  JJtd. 


connected   with   the   practice  of  medicine.      Those  .  Journ.  nnd  Examiner,  Aug.  1877. 


and,  jr.  T- 


IJAMILTQX  (ALLAN  McLANE),  M.D., 

Attfnfiii>ff  Ph»*ician  at  tht  If)*pital  f.ir  Kpilep*1c*  o-»<1  Paralytic*. 
and  at  the  Vut-l'atient*'  Dnpartme.nt  of  the.  Nftv>  York  H»*pitnl. 

NERVOUS  DISEASES;  THEIR  DESCRIPTION  AND  TREATMENT. 

In  one  handsome  octavo  volume  of  512  pages,  with  53  illua.  ;  cloth,  $3  50.  (Just  Ready.) 
The  object  of  the  author  has  been  to  fu.-nish  to  the  student  and  practitioner  in  a  cle:ir  and 
concise  form  a  guide  to  the  dingnosis  and  treatment  of  affections  of  the  nervous  system,  em- 
bodying the  very  great  advances  made  during  tbe  hist  few  years  in  our  knowledge  of  these  dis 
eases.  Unusual  opportunities  in  public  and  pri  -ate  practice  have  qualified  him  for  this  work, 
and  his  desire  has  been  to  render  it  strictly  practical,  adapting  it  to  the  wants  not  only  of  the  spe- 
cialist, but  of  tbe  general  practitioner.  Particular  care  has  therefore  b*en  devot«d  to  the  manage- 
ment of  nervous  diseases,  ami  in  an  appendix  will  be  found  a  careful  selection  of  well  tried  formulae. 
The  thorough  manner  in  which  the  subject  has  been  treated  may  be  understood  from  the  fol- 
lowing very  condensed 

SUMMARY  OF  CONTENTS. 

ISTRODUCTIOH.  Hints  in  reeard  to  Examination  and  Study  ;  Apparatus  for  the  Treatment  of 
Nervous  Disease.  Chap  I.  Diseases  of  the  Cerebral  Meninges.  Chnp.  II.  to  Chnp  VII.  Dis- 
eases of  the  Cerebrum  and  Cerebellum  Chap.  VII  Diseases  of  the  Spinal  Meningeg.  Chap, 
VIII.  to  Chap.  XII.  Diseases  of  the  Spinal  Cord.  Chap.  XII.  liultutr  Diseases  Chap.  XIII. 
to  Chap.  XV.  Cerebro-Spinal  Diseases.  Chap.  XV.  Di»ea>e«  of  the  Peripheral  Nerves.  Chap. 
XVI.  Neuritis.  Chap.  XVII.  Local  Paralyses.  Chap.  XVIII.  Lead  Poisoning  ;  Functional 
Spasm;  Professional  Cramp  :  Formulae. 


rilTARCOT  (J.  M.). 

^          Pr*fe»*artn  thf.  Hinnltyof  ifed.  Pari»,  Phy*.  fn  l,n  Salpr'rilrt,  ftr. 

LECTURES  ON  DISEASES  OF  THE  X  ENVOI'S  SYSTEM.     Trans- 

lated  from  the  Second  Edition  by  GEORGK  SIOERSOX,  M.D  ,  M  Ch.,  Lecturer  on  Biology, 
etc.,  Cath.  Univ.  of  Ireland.  With  illustrations  (Publishing  in  t/i£  Medical  Neus  and 
Library,  commencing  with  the  July  No.  1878.  See  page  2  ) 

JJUNGLISON,  FORBES,  TWEEDIE,  AND  CONOLLY. 

THE  CYCLOPAEDIA  OF   PRACTICAL  MEDICINE:   comprising 

Treatises  on  the  Nature  and  Treatment  of  Diseases,  Materia  Medica  and  Therapeutics, 
Diseases  of  Women  and  Children,  Medical  Jurisprudence,  <ko.  Ac.  In  four  large  super-royal 
octavo  volumes,  of  3254  double-columned  pages,  strongly  and  handsomely  bound  in  leather, 
$15;  cloth,  $11. 


HENRY  C.  LEA'S  PUBLICATIONS — (Practice  of  Medicine). 


17 


PWTHERGILL  (J.  MILNER},M.D.  Edin.,  M.R.C.P. 

•*-  Asst.  PhyX  tn  thf  WeM  T,nnd    Ifcxp.  ;   A*st.  Phij*.  lf>  the  Cifi/  nf  I,,-,,,!.  Hnap  ,  etc. 

THE  PRACTITIONER'S  HANDBOOK  OF  TUKATMKXT;  Or.  the 

Principle?  of  Therapeutics.     In  one  very  neat  octavo  volume  of  about  550  pages  :  cloth, 

$4  00.      (Now  Ready.) 

It  -nay  be  said  that  the  scope  of  this  work  is  not  dissimilar  to  th:it  of  the  well  known 
"  Principles  of  Medicine,''  by  Dr  J.  C.  R.  Williams,  now  long  out  of  print,  which  in  its  day 
met  with  snch  unusuul  acceptance.  More  practical  in  its  character,  however,  it  seeks  to  bring 
to  the  aid  nnd  elucidation  of  positive  therapeutics,  the  vast  accumulation  of  scientific  fnctsand 
theories  made  by  the  present  generation,  pointing  out  the  measures  to  be  adopted  at  the  bedside 
and  establishing  them  on  firm  rational  grounds.  Such  a  work,  by  a  first-iate  man,  and  fully 
up  to  the  advanced  condition  of  science,  cannot  fail  to  prove  of  the  utmost  service  to  both 
student  and  practitioner. 


Our  friends  will  find  tliis  a  very  readable  book:  and 
that  it  sheds  lighi  upon  e^ery  theme  it  touches, raOFi BIT 
the  practitioi  er  to  fee]  more  certain  of  his  diagnosis  in 
difficult  ca.ses.  We  confidently  commend  the  work  to 
our  renders  as  one  worthy  of  ca-eful  perusal.  It  liirhis 
the  way  ov"r  o'scure  and  difficult  raises  in  medical 
practice.  The  chapter  on  the  eirculntion  of  the  blood 
is  tin1  most  exhaustive  and  instructive  to  be  found.  It 
is  a  book  every  practitioner  needs,  and  would  have,  if 
be  knew  bow  siitg- stive,  and  helpful  it  would  be  to 
him. — .S'(.  /.OKI*  Mfd.  and  Surg.Jnur*.,  A^rii.  1877. 

The  object  is  one  of  the  most  important  wlncn  a  med- 
ical writer  ran  propose  to  himself,  tor  therapeutics  N  the 
goal  of  medicine,  and  the  plan  is  an  excellent  one.  In 
justice  to  l>r.  Kothergill  we  ought  to  say  that  he  has  ad- 
hered to  his  plan  throughout  the  work  with  fidelity,  ami 
has  accomplished  bis  object  with  a  rare  degree  of  success. 
We  heartily  commend  bis  book  to  the  medical  student 
ns  an  honest  and  intelligent  guide  through  the  mazes  of 
therapeutics,  and  assure  the  practitioner  who  has  grown 
gray  in  the  harness  that  he  will  derive  pleasure  and  in- 
struction from  its  perusal  The  imperfections  and 
errors  which  we  have  noticed  are  few  and  unimportant. 
On  the  other  hand,  the  excellences  are  many  and  patent. 
A'aluable  suggestions  and  material  for  thought  abound 
throughout.  The  chapters  on  body  heat  and  fever,  in- 
M animation,  action  and  inaction,  and  the  urinary  sys- 
tem are  particularly  good.  The  descriptions  of  patho- 
logical conditions,  and  the  character  of  the  therapeutic 
measures  advised  give  evidence  of  sound  clinical  obser- 
vation.- Button  Mfd.  and  Sure  Journal.  Mar  8.  1^77. 
The  strong  good  sense,  the  racy  style,  the  practical 


volume  before  us  Dr.  Fothergill  appears  in  his  best 
mood.  Our  readers,  especially  the  younger  members  of 
the  profession,  will  find  this  a  most  suggestive  aid  use- 
fulliook.  There  are  tew  old  practitioners  who  will  not 
be  benefited  by  its  perusal.  We  commend  it  to  all 
la--c-  t.f  readers,  with  the  expression  nf  belief  that  those 
who  buy  it  will  be  hardly  content  to  clc  se  it  until  the 
lu-t  leafis  turned  over.—  Cincinnati  Clinic.  Miir  'A,  1877. 
It  is  our  Iionest  conviction,  after  a  careful  perusal  of 
this  goodly  octavo,  that  it  represents  a  great  amount  of 
earnest  thought  and  painstaking  work,  and  is  therefore 
one  of  those  books  which  both  de.-crve  and  are  likely  to 
survive.  This  book,  although  written  ostensibly  tor  the 
young  and  inexperienced,  may  be  very  profitably  studied 
by  those  who  have  been  practising  their  profession 
more  or  less  empirically  for  thirty  ov  forty  years.  We 
particularly  recommend  the  chapters  on  Public  and 
I'rivate  Hygiene.  Food  in  Health  and  lll-Henlth.  and 
the  Conclusion — the  Medical  Man  at  tin-  liedside  The 
last  is  high-toned,  and  indicate-;  much  shrewdness  of  ob- 
servation. Our  space  will  not  admit  of  furtherquotation. 
We  content  ourselves  with  again  recommending  the 
book  very  cordially — E'lin.  Med.  Jmirn.,  .Ian  lf-77. 

It  isof  great  advantage  to  the  practitioner  to  have  gen- 
eral principles  to  guide  him.  and  that  he  should  not, 
when  confronted  with  an  assemblage  »f  pathological 
symptoms,  be  at  the  mercy  of  an  unreasoned  experience 
of  a  .-iiiiilar  case,  or  lie  obliged  to  swear  in  n  rha  mnyiatri. 
He  will  find  reasons  in  this  work  for  not  looking  upon 
drugs  as  grouped  in  fixed  and  unalterable  categories, 
but  learn  when  and  why  he  may  give  opium  to  cause 
purgation,  and  castor  oil  to  check  it.  We  strongly  re- 


cnaractcr  of  his  instruction,  are  qualities  in  the  author    er  mrriend  it  to  our  readers. — T/tt.  London  Practitioner, 
which  commend  him  to  American  physicians.     In  the     .Ian.  1877. 


By  the  same  Author. 

THE  ANTAGONISM  OF  THERAPEUTIC  AGENTS,  AND  WHAT 

IT  TEACHES.     Being  the  Fothergillian  Prize  Essay  for  1878.     In  one  neat  volume,  royal 

12mo.  of  about  200  pages.      (Short /y.) 

It  would  seem  unnecessary  to  call  the  attention  of  the  profession  to  a  work  on  so  suggestive  a 
subject  by  a  writer  so  brilliant  as  Dr.  Fothergill.  There  is.  perhaps,  no  one  who  has  a  better 
claim  to  be  heard,  and  no  topic  more  worthy  the  study  and  reflection  of  the  practitioner. 


T  INCOLN  (D.  F.}.  M.D., 

•*-'  Phiixician  t»  the  Department  o  f  !fr.renng  DiKf.ase.x,  Bfixtnn  Dlopf.nsiry, 

ELECTRO-THERAPEUTICS;   4.  Concise  Manual  of  Medical  Electri- 
city.    In  onevery  neatroyal  12mo.  volume,  cloth,  with  illustrations,  $1  50.     (Just  Issued.) 


ROBERTS  (  WILLIAM],  M.  D.. 

J-  **  Lecturer  on  Medicine,  in  the  Manchester  School  of  Medicine.  Ac. 

A  PRACTICAL  TREATISE  ON  URINARY  AND  RENAL  DIS- 
EASES, including  Urinary  Deposits.  Illustrated  by  numerous  cases  and  engravings.  Seo 
ond  American,  from  the  Second  Revised  and  Enlarged  London  Edition.  ID  one  large 
and  handsome  octavo  volume  of  616  pnges,  with  a  colored  plate  j  cloth,  $4  50.  (Laie/y 
Published. ] 


LECTURES  ON  THE  STUDY  OF  FEVER.      By  "A. 

HUDSON,  M.D.,  M.R.I.  A.,  Physician  to  the  Meath 

Hospital      Inonevol   Svo.,  cloth,  #2  50.  ' 

A  TREATISE  ON  FEVER.      By  ROBERT  D    Lvo.vg, 

K  C  C.     In  one  oc'.avo  volnmo  of  362  pages,  cloth, 

*2  25. 
CLIXICAL    OBSERVATIONS    ON    FUNCTIONAL 


NERVOUS  DISORDERS  BvC.  HAXDPIFI.D  JOKES 
M  D.,  Physician  to  St.  Mary's  Hospital,  &c.  Sec 
ond  American  Edition.  In  one  hH  ndsome  octavo 
volume  of  348  paees.  clol 


OX  REN'AL  DISEASES:  a  Clinical  Hnide 
to  their  Diagno.-iis  and  Treatment  With  Illnstm- 
tions.  In  one  12mo.  vol.  of  301  pages,  clo'h  - 


18        HENRY  C.  LIA'S  PUBLICATIONS — (Diseases  of  t!><>  6V*  *>*•/, 


FLINT  (AUSTIN),  M.D., 

•*-  Professor  of  the  Principle*  and  Practice  of  Medicine  in  Bellevue  Hoxpital  Med.  College,  F.  J. 

PHTHISIS:  ITS  MORBID  ANATOMY,  ETIOLOGY.  SYMPTOM- 
ATIC EVENTS   AND  COMPLICATIONS,  FATALITY   AND   PROGNOSIS,  TREAT- 
MENT,  AND  PHYSICAL  DIAGNOSIS;    in  a  series  of  Clinical  Studies.     By  ATSTIN 
FLINT,  M.D.,  Prof,  of  the  Principles  and  Practice  of  Medicine  in  Hcllevue  He  f|iit;il  Med. 
College,  New  York.     In  one  handsome  octavo  volume  :  $3  50      (Lately  Issuni .) 
This  volume,  containing  the  results  of  the  author's  extended  observation  nnd  experience  on  a 
subject  of  prime  importance,  cannot  but  have  a  claim  upon  the  attention  of  every  practitioner. 
This  book  contains  an  analysis,  in  the  author'*  lucid      Mtioner.    While  the  author  take?  ls*ni>  with  ninn 

leading  mind*  of  the  day  on  importaiitquestions  arising 
in  the  study  of  ;>htliiMF.  the  strong  testimony  of  expe- 
rience and  authority  will  have  threat  weight  with  the 
soekcr  after  truth  As  the  result  ofclinicul  Mudy.  the 
work  is  unequalled. — St.  Lou.it  Med.  and  Kurg  Juurnnl, 
March,  187«. 


style,  of  the  notes  which  he  hast  made  in  several  hun- 
dred cases  in  hospital  and  private  practice.  We  com 
mend  the  book  to  the  perusal  of  all  interested  in  the 
study  of  this  disease. — Boston  Med.  and  Sura.  Journal, 
Feb  10,  1876. 


The  name  of  the  author  is  a  sufficient  guarantee  that 
this  book  iit  of  practical  value  to  both  student  and  prac- 


ftY  THE  SAME  AUTHOR.    (Just  Issued .) 

A  MANUAL   OF  PERCUSSION  AND   AUSCULTATION;   of  the 

Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism.    In 
one  handsome  royal  12mo.  volume:  cloth,  $1  75. 

In  this  little  work  the  object  of  the  author  has  been  to  present  in  a  clear  and  compact  form 
the  existing  condition  of  physical  exploration,  showing  the  manner  of  conducting  it  and  the 
diagnostic  value  of  the  several  signs  thereby  elicited. 

We  can  confidently  recommend  this  treatise  to  all  I  rightly  value  lhe»e  modes  of  exploration  of  disease, 
who  would  leara  auscultation  aud  percussion,  and  |  —Briftshund  Far.  Ifeit.-GMr  Rw.,  July,  1x7. 


T>  r  THE  ft  A  ME  A  UTHOR. 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS,  PATHOLOGY, 

AND  TREATMENT  OF  DISEASES  OF  THE  HEART.     Second  revised  an,l  enlarged 
edition.     In  one  octavo  volume  of  550  pages,  with  a  plate,  cloth,  $4. 

Dr  Flint  chose  a  difficult  subject  for  hU  researches,  tnd  clearest  practical  treatise  on  those  subject*,  and 
and  has  shown  remarkable  powers  of  observation  .honld  be  in  the  hands  of  all  practitioner  aud  stu- 
tnd  reflection  as  well  as  great  industry,  in  his  treat-  lent*  It  is  a  credit  to  American  medical  literature, 
meat  of  it.  His  book  must  be  considered  the  fullest ,  -Amer.  Journ.  of  the  Med  Sciences,  July,  1860. 

T)Y  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST  AND  THE  DIAGNOSIS  OF  DISEASES  AFFECTING  THB 
RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  handsome  octavo  volume 
of  595  pages,  cloth,  $4  50. 

Dr.  Flint's  'realise  is  one  of  the  most  trustworthy  i  >ncy  to  over-refinement  and  unnecessary  minuteness 
(aides  which  we  can  consult.  The  ->tyle  in  clear  and  j  rhich  characterize*  many  work*  on  tb'<>  name  *nb- 
dlstinct,  and  is  also  concise,  being  free  from  that  tend-  j*ct.—  HvMin  Medical  Press,  Feb.  6,  1867. 


W 


WILLIAMS  (C.J.B.),  M.D., 

Senior  ConmiUing  Physician  tothe  Hospital  for  Consumption.  Brompton. 

PULMONARY  CONSUMPTION;  Its  Nature.  •Varieties,  and  Treat- 
ment. With  an  Analysis  of  One  Thousand  Cases  to  exemplify  its  duration.  In  one  neat 
octavo  volume  of  about  350  pages,  cloth,  $2  50.  (Lately  Published.) 


(CHAMBERS  (T.  K.),  M.D.. 

vX  Consulting  PhysiHan  to  St.  Mary's  Hospital,  London,  Ac. 

A  MANUAL  OF  DIET  AND  REGIMEN  IN  HEALTH  AND  SICK- 

NESS.     In  one  handsome  octavo  volume.     Cloth,  $2  75.       (Just  Issued.) 


DIPHTHERIA  ;  its  Nature  and  Treat  «i«ot,  with  an 
account  of  the  History  of  its  Prevalence  in  vart- 
ons  Countries.  By  D  D  SI.ADK,  M.D.  Second  and 
revised  edition.  In  one  neat  royal  12mo.  volume, 
cloth,  91  -J.V 

WALSHE  ON  THE  DISEASES  OF  THE  HEART  AN) 
GREAT  VESSELS.  Third  American  edition.  In 
1  »nl.  STO  .  490  ni>..  r1«tli  *<»  on 

FULLER  ON  DISEASES  OF  THE  LUNOS  AND  AIR- 
PASSAGES.  Their  Pathology,  Physical  Diagnosis. 
Symptoms,  and  Treatment.  From  'the  second  and 
revised  English  edition.  In  one  hamlsome  octavo 
volnme  of  about  500  pages  :  cloth,  $3  .">0. 

LA  ROCHE  ON  PNEUMONIA.  1  vol.  8vo.,  cloth, 
of  500  page*  Price  $S  00. 

SMITH  ON  CONSUMPTION  ;  ITS  EARLY  AND  RE- 
MEDIABLE STAGES.  1  vol.  8vo.,pp.254.  |2  2fi 


LECTURES  ON  THE  DISEASES  OF  THE  STOMACH. 
With  nil  Introduction  on  its  Anatomy  and  Physio- 
logy. By  WII.UAM  RKIVTOX.  M  I)..  K  K  S  From 
the  second  and  enlarged  Lon  Anedition.  With  11- 
1'iMratinns  on  wood  In  one  handsome  octavo 
volume  of  about  300  pages:  cloth,  *:i  I.',. 

CHAMBERS'S  RESTORATIVE  MEOKUNE  An  Har- 
veian  Annual  Oration.  With  Two  Se'|iipls  Fn 
one  very  handsome  vol.  small  12mo  ,  cl"th,  §1  00. 

PAWS  TREAT. SE  ON  THK  FI'N'TION  OF  DI- 
•  iESTMX;  it«  Disorders  and  their  Treatment. 
From  the  second  London  edition.  In  one  hand- 
some volume,  small  octavo,  cloth,  $2  00. 

PAVY'S  TREATISE  ON  FOOD  AND  DIETETICS. 
PbT»iologfc*lly  and  Therapeutically  Con^iipred. 
In  one  handsome  octavo  volume  of  nearly  600 
pages,  cloth,  $4  75. 


__  HENRY  C.  LEA'S  PUBLICATIONS—  (  Venereal  Digeases,  &c.).          19 
ftUMSTEAD  (FREEMAN  J.},  M.  /)., 

•*-*        Profissor  of  Venereal  Diseases  at  the  Col.  of  Phys  and  Surg    ffete  York  Ac 

THE  PATHOLOGY  AND  TREATMENT  OF  VENEREAL  DIS- 

EASES.  Including  the  results  of  recent  investigations  upon  the  subject.  Third  edition, 
revised  and  enlarged,  with  illustrations.  In  one  large  and  handsome  octavo  volume  of 
over  700  pages,  cloth,  $5  00  ;  leather,  $6  00. 

In  preparing  this  standard  work  again  for  the  press,  the  author  has  subjected  it  to  a  very 
thorough  revision.  Many  portions  have  been  rewritten,  and  much  new  mutter  added,  in  order  to 
bring  it  completely  on  a  level  with  the  most  advanced  condition  of  gyphilography,  but  by  careful 
compression  of  the  text  of  previous  editions,  the  work  has  been  increased  by  only  sixty-four  pages. 
The  labor  thus  bestowed  upon  it.  it  is  hoped,  will  insure  for  it  a  continuance  of  its  position  as  • 
complete  and  trustworthy  guide  for  the  practitioner. 

A  valuable  work  on  Venereal  Diseases,  which  not      venereal  diseases,  that  it  may  seem  almost  sKperflu- 


,  ,  - 

nnlyhas  a  wide  circulation   in    Ibis  country,  and     ons  to  say  more  of  it  than  that  a  new  edition  has  been 
been  accepted  a«  the  standard,  bnt  appears  tolnve      Usued.     But  the  author's  industry  has  rendered  this 
formed  the  basis.  10  a  large  extent,  of  many  of  the 
books  and  article-  which  have  been  written  on  the 


same  subject  and 

.  J  urn..  Oct.  18 


in  England.  -  The  Olat- 


. 

n»w  edition  virtually  a   new  work  and  so  merits  as 
:  much  special  commendation  a*  if  lt«  predecessor-  baa 
,  Dot  been  published      As  a  thoroughly  practical  book 
..  ..         .          .  ;  on  a  clas'8  of  d,Reases  which  for*    /  /arge  Khare  of 

It  is  the  most  complete  bonk  with  which  we  are  ac-  nearly  every  physician's  practice,  the  volume  befor* 
quainted  in  the  language.  The  latest  vi_ews  of  the  ns  is  by  far  the  best  of  which  we  have  knowledge.— 
best  authorities  are  put  forward,  and  the  information  -V  r.  Jfedteal  Gazette.  Jan  28.  1871 
is  well  arranged—  a  great  point  for  the  student,  and  u  ;8  rare  IQ  thp  history  of  medicine  to  find  any  on* 
BtiiJ  more  for  .he  practiUoner.  The  subjects  of  vis-  brtok  wljich  con,ain(i  ,n  tha,  a  practitioner  need!  to 
ce.-al  syphilis  syphilitic  affections  of  the  eyes,  and  know;  wllile  the  j)OSBe(18or  ,,f  «•  i<nra<tead  on  Vene- 
the  treatment  of  syphilis  by  repeated  inoculations,  are  I  rear-  has  n,,  occagi,)n  to  jook  outside  of  iu  covers  for 
very  fully  discussed.—  London  Lancet.  Jan  7.  1871  j  anytbing  practicili  connected  with  the  diagnosis,  hi.- 

Dr.   Bumstead's   work   is  already  so  universally  |  tory,  or  treatment  of  these  affections  —  N.  Y  Medical 
kaown  as  the  best  treatise  in  the  English  language  on  |  Jonrnnl   March,  1871. 


riULLERIER  (A.},  and 

v         Surgeon  to  the  Hdpital  du  Midi. 


~DUMSTEAD  (FREEMAN  J.). 

•*-*        Professor  of  Vf.ntrm  I  IHx-aneg  in  the  College  o) 
Phy*iritinKnnd  Surgeons.  A".  7. 

AN  ATLAS  OF  VENEREAL  DISEASES.     Translated  and  Edited  by 

FREEMAN  J.  BUMSTEAD.     In  one  large  imperial  4to.  volume  of  328  pages,  double-columns, 
with  2fi  plates,  containing  about  150  figures,  beautifully  colored,  many  of  them  the  size  of 
life;  strongly  bound  in  cloth,  $17  00  ;  also,  in  five  parts,  stout  wrappers,  at  $3  per  part. 
Anticipating  a  very  large  sale  for  this  work,  it  is  offered  at  the  very  low  price  of  THREE  DOL- 
LARS a  Part,  thus  placing  it  within  the  reach  of  all  who  are  interested  in  this  department  of  prac- 
tice.    Gentlemen  desiring  early  impressions  of  the  plates  would  do  well  to  order  it  without  delay. 
A  specimen  of  the  plates  and  text  sent  free  by  mail,  on  receipt  of  25  cents. 

We  wish  for  once  that  our  province  WHS  not  restrict-  to  its  end,  we  do  not  know  a  single  medical  work, 
•d  to  methods  of  treatment,  that  we  might  say  some-  .  which  for  its  kind  is  more  nec«gnary  for  them  to  have. 
thing  of  the  exquisite  colored  plates  in  this  volume.  —Oalifornifi  Mfd.  flnzrtte.  March  1869. 


—London  Practitioner,  May,  1869. 


The  most  splendldiy  illustrated  work  in  the  Ian- 


As  a  whole,  it  teaches  all  that  can  be  taught  by  $nage,  and  in  our  opinion  far  more  useful  than  tha 
means  of  plates  and  print.—  London  Lancet.  March  I  ?ren<ib  original  —  Am  Jnurn.  Jfed.  Scienctf,  Jan.  6fe. 
13,1865.  ;  The  fifth  and  concluding  nnmberof  this  magnificent 

Superior  to  nnythlng  of  the  kind  ever  before  issued  work  has  reached  ns,  and  we  have  f  he»itatiop  in 
on  this  continent.  —  Canndfi  .Ifwl.  Journal.  March,  'R9.  saying  that  its  illn-trations  snrpas-  those  of  previoui 

The  practitioner  who  desires  to  understand  this     numbers       KW  1/W  and  Surg.  J-.,  Jan.  1 
branch  of  medicine  thoroughly  should  obtain  this,         Other  writers  besides  M.  Cullerier  h»v*>  given  as  a 
the  most  complete  and  best  w^rk  ever  published.—     good  aicouut  of  the  diseases  of  which  he  treats,  bul 
Dominion  3ffd.  Journal.  May,  1869.  j  '„„  One  has  furnished  us  with  sorb  a  complete  serie* 

This  Is  a  work  of  master  hands  on  both  sides.     M    :  of  illustrations  of  the  venereal  diseases      There  i», 
Cnllerier  is  scarcely  second  to,  wethink  wemay  truly  ,  however,  an  additional  interest  and  valnepog! 
tay  is  a  peer  of  the  illustrious  and  venerable  Ricord,  j  by  the  volume  before  us  ;  for  it  is  an  A  mericau 
while  in  this  country  we  do  not  hesitate  to  say  that  :  xnd    translation  of  M.  Cnllerier'i  work,  w 
Pr.  Bnmstead,  as  an  authority,  is  without  a  rival      dental  remarks  by  oneof  the  most  eminent  A 
A:-sunn,c  our  readers  that  these  illustration.-  tell  the    «  vph  Uographem,    Mr.    Hnmstend.  —  Brit.   < 
whole,  history  of  venereal  disease,  from  its  inception     V«ff<-n-  "M«-  .  Review,  July,  1869. 

7"  EE  (HENRY), 

Prof,  of  Surgery  at  the,  K^ynl  OolJfat  of  Surgeon*  of  England,  etc. 

LECTURES  ON  SYPHILIS  AND  ON  SOME  FORMS  OF  LOCAL 

DISEASE  AFFECTING  PRINCIPALLY  THE  ORGANS  OF  GENERATION 
handsome  octavo  volume:  cloth;  $2  25.     (Late/i/  Published.) 

moditiririKi!-  ol'tti.-r  jT<>fe--s.'s  in  pnti.'ii's  pre»iouily 
^vpbi'itic:  primnry  :in,l  M-rnn.inry  syphilitic  <ti- 
tbi-  nuicoii<  tnenihrant'S  and  their  liability   to  rommu- 
olcate  .•<.n-iiin1i>'i!:ii  <\-('b:!i«.  rtc.     Tl"-  book   i-  full  of 
clinical   nint.-rin'   lllnrtrtHnK  tli<--  nal   or 

quoted.—  Arc/iires  "f  f>trmal»l»sy.  April.  ! 


The  work  is  valuable,  as  it  treats  quite  fully  of  sub 
eets  which  are  not  dwelt  upon  in  the  systematic  works 
of  ot'-r-r  Kiislisti  authors  of  tbe  present  (lay.  a*  the  info 
ulaWHty  of  syphilitic  blood:  f  he  con.  lit  dm  <  nivler  which 
tlii'  secretions  of  primary  and  secondary  syphi'ilic  man- 
ifestMion*  mav  be  inoculated  natunillv  or  artitici.-iHy : 
the  morbid  processes  produced  by  such  inoculation :  the 


res  " 


fTILL  (BERKELEY], 

Surgeon  to  the  Lock  Ho.<ri>1tnl.   London. 

OX  SYPHILIS   AXD   LOCAL  CONTAGIOUS  DISORI 

one  handsome  octavo  volume  ;  cloth,  $3  25. 


20         HENRY  C.  LEA'S  PUBLICATIONS — (Diseases  of  the  S*TV,  fir.). 
tfO X  (TILnURF),Af.D.,F.R.C.P.,av<l  T.  C.  FOX,  D.A.,  M.R.C.S., 

•*-  Physi(-inn  to  the  Department  for  Skin  Diseases,  Utiivtrnitji  ('<///»</'  //<«,?. i/«/. 

EPITOME  OF  SKIN  DISEASES.     WITH  FOK.MUL/E.     FOR  STU- 

DBNTS  AND  PttACTiTiOBK KB.  In  one  handsome  12mo.  volume,  of  120  pages:  cloth,  $1. 
(Just  Issued.)  . 

A  very  clear  and  conci-e  description  is  iriven  of  the  treatmuntof  skin  diseases  are  accurately  and  compl.-tely 
elementary  lesions  aid  ihe  author's  remarks  "n  the  staled  without  Iteintr  cramped.  The  l>ook  is  -,.  well  :ir- 
geii'-ral  character,  coinplicalions.  «nd  modifications  of  ranged  that  tlie  reader  will  have  no  difficulty  in  tindin;; 
eroption*.  totr°tberirith  th-Ir  practical  hlnta on  the  ex-  at  once  exactly  tlie  Information  he  mny  require  A 
ami  tuition  of  skin  diseases,  will  1  e  of  ereat  »»«istance  csirefully  compiled  formulary  of  remedies  tor  skin  11  (Tee- 
to  the  novice  in  this  department  of  medicine.  We  know  tions  and  some  notes  on  dirt  in  skin  disease*,  '•'•nsidern- 
of  no  other  which,  in  so  little  space  contains  so  much  lily  enhance  the  value  of  the  epitome.— London  Lancet. 
reliable  information.— N.  Y.  MtJ.  Jmirn..  Dec.  1S7«.  j  Nov.  4,  1876. 

It  bus  no  especial  features  other  than  it  Is  concis-  and  '  It  must  be  admitted  that  even  those  well  prcpar'-d  fur 
quite  practical.  The  early  chapters,  treating  of  ele-  general  practice  find  diseases  of  the  skin  dithVult  of  clas- 
mentary  matters, in  the  study  of  sMn  diseases,  are  very  sificati  >n,  and  HS  difficult  of  diii^nosis.  and  that  nothing 
pood,  and  the  list  of  formulae  is  excellent.— Archives  of  is  more  desirable  than  some  work  wliic-li.  not  >  htlmritte 
Clinical  Kurge'y,  Dec.  1876.  i"  nature,  shall  be  a  useful  ordinary  puide.  :in  I  is-m-d 

If  doctors  neiclect  the  study  of  diseases  of  the  skin,  it     J>y  «»n»  •>«>•  of  recognized  authority.  It  b  Mfamdthtt 


ried  in  the  pocket,  while  the  text  furnishes  briefly,  tint 
clearly,  the  information 
tinner.    It  meets  fully  a 
points  of  the  classification,  diagnosis,  symptoms,  and     ja.  Weekly,  Jan.  6,  1877. 


, 

This  little  work  cannot  fail  to  acquire  a  large  circle  of    clearly,  the  information  desired  by  tlie  general  practi- 
readers.     In   a  very  small   compass  all   the  essential     tinner.    It  meets  fully  an  almost  universal  want.—  -4m. 


TXTILSON  (ERASMUS),  F.R.S. 

ON  DISEASES  OF  THE  SKIN.     With  Illustrations  on  wood.    Sev- 

enth American,  from  the  sixth  and  enlarged  English  edition.     In  one  large  octavo  volume 
of  over  800  pages,  $5. 

A  SERIES  OF   PLATES  ILLUSTRATING  "WILSON   ON   DIS- 

EASES OF  THE  SKIN;"  consisting  of  twenty  beautifully  executed  plates,  of  which  thir- 
teen are  exquisitely  colored,  presenting  the  Normal  Anatomy  and  Pathology  of  the  Skin, 
and  embracing  accurate  representations  of  about  one  hundred  varieties  of  disease,  most  of 
them  the  size  of  nature.     Price,  in  extra  cloth,  $5  60. 
Also,  the  Text  and  Plates,  bound  in  one  handsome  volume.     Cloth,  $10. 
J$Y  THE  SAME  AUTHOR.  - 

THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE  and  DIB- 

KABES  or  THE  SKIN.   In  one  very  handsome  royal  12mo.  volume.   $3  50. 


(J.MOORE),  M.D.,M.R.I.A. 

ATLAS  OF  CUTANEOUS  DISEASES.  In  one  beautiful  quarto 
volume,  with  exquisitely  colored  plates,  Ac.,  presenting  about  one  hundred  varieties  ot 
disease.  Cloth,  $5  50. 


The  diagnosis  of  eruptive  disease,  however,  under 
all  circumstances,  Is  very  difficult.  Nevertheless, 
Dr.  Neligan  has  certainly,  "as  far  as  possible,'' given 
ft  faithful  and  accurate  representation  of  this  class  of 
diseases,  and  there  can  be  no  doubt  that  these  plates 
will  he  of  great  use  to  the  student  and  practitioner  in 
drawing  a  diagnosis  as  to  the  class,  order,  and  species 


to  which  the  particular  case  may  belong.  While 
ooking  over  the  "Atlas"  we  have  been  induced  to 
<xamine  also  the  "Practical  Treatise."  and  we  are 
inclined  to  consider  it  a  very  superior  work,  oon_- 
bining  accurate  verbal  description  with  sound  view* 
of  the  pathology  and  \reatment  of  eruptive  diseases. 
—  Glasgow  Med.  Journal. 


IJILLIER  (THOMAS),  M.D., 

Physician  to  the  Skin  Department  of  University  College  Hospital,  **. 

HAND-BOOK  OF  SKIN  DISEASES,  for  Students  and  Practitioners. 

Second  Am.  Ed.     In  one  royal  12mo.  vol.  of  358  pp.    With  Illustration!*     Cloth,  $2  25. 

We  can  conscientiously  recommend  it  to  the  stn- 1      It  is  it  concise,  plain,  practical  treatise  on  the  varl- 

dent ;   the  style  is  clear  and  pleasant  to  read,  the    ons  diseases  of  the  skin  ;  just  such  a  work,  indeed, 

matter  is  good,  and  the  descriptions  of  disease,  with    as  was  much  needed,  both  by  medical  students  and 


„_.,  -.„„_„„„ 

as  was  much  needed,  both  by  medica    s 

practitioners.  —  Chicago  Medical  Examiner,  May, 


18«5. 


matter  is  good,  and  the  descriptions  of  disease,  with 
•he  modes  of  treatment  recommended,  are  frequently 
lllistrated  with  well-recorded  cases.— London  M?,d. 
Times  and  (Jaxette.  April  1.  1865. 

&MITH  (EUSTA CE),  M.  D^~ 

Physician  to  the  Northwest  London  Free  Dispensary  for  Sick  Children. 

A  PRACTICAL  TREATISE  ON   THE  WASTING   DISEASES  OF 

INFANCY  AND  CHILDHOOD.    Second  American,  from  the  second  revised  and  enlarged 
English  edition.     In  one  handsome  octavo  volume,  cloth,  $2  50.     (Lately  Issued.) 
'  .  !.8.in  8Te.ry  wav  an  »dmiraAle  book.     The    scribed  as  a  practical  handbook  of  the  common  di*- 


modest  title  which  the  author  has  chosen  forit  scarce 
ly  conveys  an  adequate  idea  of  the  many  t-ubjecU 
npon  which  it  treats.  Wasting  is  <o  constant  an  at- 
tendant upon  the  maladies  of  childhood,  thxt  a  trea- 
tise npon  the  wasting  diseases  of  children  must  neces 


ea!>es  of  children,  so  numerous  are  the  affections  con- 
(iidered  either  collaterally  or  directly.  We  are 
acquainted  with  no  safer  guide  to  the  treatment  of 
children's  diseases,  and  few  works  give  the  insight 
into  the  physiological  and  other  peculiarities  of  chil- 


- 

»arily  embrace  the  consideration  of  many  affections    dren  that  Dr.  Smith's  book  does. — Brit.  Med,  Journ., 
of  which  it  is  a  symptom  ;  and  this  is  excellently  well    April  8,  1871. 
dona  by  Dr.  Smith.    The  book  might  fairly  be  de- 1 


HENRY  C.  LEA'S  PUBLICATIONS — (Diseases  of  Children).  21 

SMITH  (J.  LE  WIS),  M.  D., 

*3  Professor  of  Morbid  Anatomy  in  the  Bellevue  Hospital  Sfed.  College,  ff.  T. 

A  COMPLETE  PRACTICAL  TREATISE  ON  THE  DISEASES  OF 

CHILDREN.    Third  Edition,  revised  and  enlarged.     In  one  handsome  octavo  volume 
of  726  pages.    Cloth,  $5  ;  leather,  $6.      (Just  Issued.) 

The  eminent  success  which  this  work  has  achieved  has  encouraged  the  author,  in  preparing 
this  third  edition,  to  render  it  even  more  worthy  thmi  heretofore  of  the  fnvor  of  the  profession. 
It  has  been  thoroughly  revised,  and  very  considerable  additions  have  been  made  throughout. 
To  accommodate  these  the  volume  has  been  printed  in  a  smaller  type,  so  as  to  prevent  any 
notable  increase  in  it*  size,  and  it  is  presented  in  the  hope  that  it  may  attain  the  position  of 
the  American  text  book  on  this  important  department  of  medical  science. 

This  work  took  a  stand  as  an  authority  from  its  first  edition  will  confirm  and  add  to  its  reputation.    Having 

appearance.  and  everyone  imeivste;!  in  studying  the  been  brought  up  to  the  present  mark  in  the  rapid  ml- 

diseases  of  which  it  treats  is  desirous  of  knowing  what  vauce  of   medical  science,  it  is  the  best  work   in  our 

improvements  are  apparent  in  the  successive  editions,  language,  on  its  ran>_'e  of  topics,  for  the  American  prac- 

The  principal  additions  to  which  we  n  fer.  mid  which  titioner. — Pacific  Mtd.  anil  Sitrg.  Jourti..  Feb.  1-7 f>. 


rill  be  the  di.stinguishing  features  of  the  third  eJitiuu. 
are  chapters  on  diphtheria,  cerebro-spinal  meningitis, 
and  riirheln.  The  former  disease  is  considered  much 


Dr.  Smith's  Diseases  of  Children  is  certainly  the  most 
valuable  work  on  the  subjects  treated  that  the  practi- 
tioner can  provide  himself  with.  It  is  fully  abreast 


more  in  detail  than  formerly,  and  a  great  amount  of    witn  every  advance:  it  should  be  in  the  bunds  of  prac- 

very  practical  information  is  added,  and  altogether  it  is  tjtjoners  generally,  while,  because  of  the  conciseness 

one  of  the  most  comprehensive  and  one  of  the  best  writ-  aM,|  c]earness  of  style  of  the  writing  of  the  author.  every 

ten  chapters  of  the  subject  we  have  thus  far  read.     His  pr(lfe!,sor  of  diseases  of  children,  if  he  has  not  already 

description  of  cerebro  spinal  meningitis,  founded  also  ,|one  SO(  should  adopt  this  as  his  text-book  —  Va  .  Medical 

for  the  most  part  on  personal  experience,  is  admirably  \fynMy  Feb  1876 
clear  and  exhaustive.-'/^  JM.  Record,  Feb.  19,  1876.    (      ^  ^.^  ^^  of  ^  ^^  Talu8He  work  is  now 


In  presenting  this  deservedly  popular  treatise  for  the  i)ef(,re  us-  wj|n  a  hundred  pages  of  additional  matter 

third  time  to  the  profession.  Dr.  Smith  ha?  given  it  a  .,„  ;,it,.red  si/.e  of  paue.  new  illustrations,  and  nc 

careful  preparation,  which  will  make  it  of  decided  su-  Q(-  ,iie  jjseases  treated  of  for  the  first  time,  we  notice 

periority  to  either  of  the  former  editions.    The  position  rotnein  anj  cerebro-spina!  fever,  which  lately  prevailed 
of  the  author,  as  physician  and  consultant  to  several  |  jn  epjfieniic  form  in  some  parts  of  the  country.    The 

large  children's  hospitals  in   New   York  City,  has  fur-  artjc|e  upon  diphtheria,  containing  the  latest  develop- 

ni-hed  him  with  constant  occasions  to  put  his  treatment  nients  \n  the  pathology  and  treatment  of  that  dread  dis- 

to  the  test,  and  his  work  has  at  once  that  practical  and  t,.lM,   w|,j,.n  so  lately  ravaged  our  country,  is  peculiarly 

thoughtful  tone  which  is  a  marked  characteristic  ot  the  interesting  to  every  practitioner.     We  glaitlv  welcome 

be-t  productions  of  the  American  medical  press.—  Mtd.  tllis  standard  work.'and  cheerfully  recommend  it  to  our 

and  Surg.  Rtporlrr,  Feb.  IsTiJ.  readers  as  tlie  >iest  on  this  subject  in  the   Fnulish   larc- 

The  former  editions  of  this  book  have  civen  it  the  guage.—  SaihrWe  Journal  of  Med.  and  Surgery,  March, 

highest  rank  among  works  of  its  class,  and  the  present  1876. 


rtONDIE  (D.  FRANCIS),  M.  D. 

^  A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILDREN. 

Sixth  edition,  revised  and  augmented.     In  one  large  octavo  volume  of  nearly  800  closely- 

printed  pages,  cloth,  $5  25  ;  leather,  $6  25. 

The  present  edition,  which  is  the  sixth,  is  fully  up  I  teachers.    As  a  whole  however   the ^work  i ^  the  ^*| 
tothettmesln  the  discussion  of  all  those  polntsiu  the  |  American  one  that  we  have,  and  nits 
pathology  and  treatment  of  infantile  diseases  which  I  -.ion   to  American  prHctinoners  it  c«tainly -has   no 
have  befn  brought  forward  by  the  Germau^nd  French  |  ,qual.-Jfe»  York  M«d.  Record,  March  2,  1888. 


(CHARLES),  M.  D., 

Physician  to  the  Hospital  for  Sick  Children,  *c. 

LECTURES  ON   THE   DISEASES   OF   INFANCY  AND  CI 

HOOD.     Fifth  American  from  the  sixth  revised  and  enlarged  English  edition.     In  one  large 
and  handsome  octavo  volume  of  678  pages.    Cloth,  $4  50  ;  leather,  $5  50.    (Latt 'y  « 
The  continued  demand  for  this  work  on  both  sides  of  the  Atlantic,  and  its  translation  into  Ger- 
man, French    Italian,  Danish,  Dutch,  and  Russian,  show  that  it  fills  satisfactorily  a 
sively  felt  by  the  profession.     There  is  probably  no  man  living  who  can  speak  «  itl  HJ 

derived  from  a  more  extended  experience  than  Dr.  West,  and  his  work  now  prese: 
nearly  2000  recorded  cases,  and  600  post-mortem  examinations  selected  Irom  among  n 
cases  which  have  pnssed  under  his  care.     In  the  preparation  of  the  present  edition  1 
much  that  appeared  of  minor  importance,  in  order  to  find  room  for  the  introduction  of 
matter,  and  the  volume,  while  thoroughly  revised,  is  therefore  not  increased  mater 

Of  all  the  English  writers  on  the  diseases  of  chil-  I  living  authorities  in  the  difficult  ^rartnient  of  medj 
4rea.  there  is  no  one  so  entirely  satisfactory  to  us  as  I  cal  scieuce  in  winch  he  w   most   »U< 
T>r.  West.     For  years  we  have  held  his  opinion  as  I  Boston  Med.  and  Surg.  Sou 
judicial,  and  have  regarded  him  as  one  of  the  highest  | 

D  7  THE  SAME  AUTHOR.    (Lately  Issued.) 

ON  SOME  DISORDERS  OF  THE  NERVOUS  SYSTEM  IN  CHILD. 

HOOD;  being  the  Lumleian  Lectures  delivered  at  the  Royal  College  of  Physicians  o 
don,  in  March,  1871.     In  one  volume,  small  12mo.,  cloth,  $. 


22 


HKNBY  C.  LKA'S  PUBLICATIONS — (Diseases  of  Women). 


/THOMAS  (T.GAILLARD},M.D., 

Professor  of  Obntetrics,  Ac.,  in  the  College  of  Physicians  and  Surgeons,  N.  r.,  Ac. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  WOMEN.   Fourth 

edition,  enlarged  and  thoroughly  revised.     In  one  large  and  handsome  octavo  volume  of 
800  pages,  with  191  illustrations.     Cloth,  $5  00;  leather,  $6  00.     (Just  Issn- 

The  author  has  taken  advantage  of  the  opportunity  afforded  by  the  call  for  another  edition  of 
this  work  to  render  it  worthy  a  continuance  of  the  very  remarkable  favor  with  which  it  has  been 
received.  Every  portion  has  been  subjected  to  a  conscientious  revision,  and  no  labor  h:is  been 
spared  to  make  it  a  complete  treatise  on  the  most  advanced  condition  of  its  important  subject. 

A  work  which  has  readied  a  fourth  edition,  mill  eiou  would  remark  that,  as  a  teacherofgynaec 
that.  to...  in  ill.-  short  spare  of  five  year*,  l.as  achieved  both  didacticand  clinical,  Prof.  Thorn*  -  In- certainly 
a  re|iiii:ition  which  place*  it  almost  U-yond  the  reach  takeo  the  lend  far  ahead  of  his  ennfren.t,  au.1  as  no 
of  criticism,  ami  the  favorable  opinions" which  we  hnve  author  he  certainly  has  met  with  unuMial  and  mer- 
already  expressed  of  the  former  editions  g^m  to  re-  Hed  success.—  Am  Jnurn.  <>f  Obstetric.*,  Nov.  1874. 
quire  that  we  should  do  little  more  than  announce  This  volume  of  Prof.  Thomas  in  it*  revised  form 
this  new  issue  We  cannot  re'rain  from  snyinz  that.  is  cias,ical  without  being  pedantic,  full  in  ihe  details 
as  a  practical  work,  this  is  second  to  none  in  the  Kn|<-  of  aDatom'_  and  pathology,  without  ponderous 
lisb,  or.  indeed,  in  any  other  language.  The  arrant.'*-  translation  of  pages  of  Gerrain  literature,  describes 
ment  of  the  contents,  the  admirably  clear  manner  in  ai«tiDcr|y  the  details  and  difficulties  of  each  ouera- 
whirh  the  subject  of  the  differential  diagnosis  of  ,jon>  withont  wearying  and  nseless  minutiie,  and  is 


injf  litfht  and  instruction.  Dr  Tlioma»  is  a  man  with  a 
very  dear  I..-:,,!  and  deride,!  view-.  ,,,,,l  there  seems  to 
be  nothing  which  he  so  much  dislikes  KS  ha/y  notions 
of  diagnosis  and  blind  routine  and  unreasonable  thera 


,     .  .,  (ll 

„  Professor  Thomas  fairly  took  the  Profession  of  t 

ani'«<l  s'ate«  b7  S1torl"jwhfin  hls  ho".k 

of  diagnosis  and  blind  routine  and  unreasonable  thera-      "Pl'earnnce  early  in  IS68.     Its  reception  was  simply 
peuticj..     The  student  who  will  thoro.urMv  studv  this     enthusiastic,    not  withstanding  a  few   advers, 
book  and  test  its  principles  bv  clinical  observation,  will     «is"i-  from  our  transatlantic  brethren,  I  h-  ti 
certainly  not  be  guilty  of  these  faultc.-Lonrfon  Lancet,     edition  was  rapidly  exhausted,  and  in  six  months  a 
Feb.  18,  I8T-5.  ,  second  one  was  issaed,  and  in  two  years  a  third 


The  latest  edition  of  this  well-known  text-book 


....  illt  i    -      ,  i  Jl_  II1  l«CU     I  IIC    MJUIIU.  I    11*3      l*\.jj«n*»tfcj     "  •     *•••" 

retains  the  essential  chnracters  which  rendered  the      not  ephemerai.  aDd  its  success  was  unprecedented  in 
earliest  so  deservedly  popular     It  I*  sdll  pre-emi- 
nently a  practical  manual,  Intended  to  convey  to 
students  in  a  clear  and  forcible  miuner  a  sufficiently 


was  announced  aud  published,  and  we  are  now  pro- 
mised the  fourth.     The  popularity  of  this  work  was 


the  annalsof  American  medical  literature  Six  years 
is  a  long  period  in  medical  scientific  research,  but 
Thomas's  work  on  "  Diseases  of  Women"  is,  still  thf 


.  ..  _  ,  r  .  lUUIIInnoVTUInUU&s  tocf*-"T3r,    VI      "    V»M  v« 

complete  ontl'ne  of  gymecology  In  a  word,  we  leadin,.  native  production  of  the  United  States  The 
should  saT  that  any  one  who  intended  to  make  a  order  8the  ,nat,er,  the  absence  of  theoretical  disputa- 
special  study  of  gynwcology  could  hardly  do  belter  tlyeneg!<  the  fairness  ,,f  statement,  aud  the  elegance 
than  tobegmwithaminutepernsalofthiKbook, and  .  of  djction,  preserved  throughout  the  entire  range  of 
tha  any  one  who  intended  to  keep  gynjecology  sub-  th  book  '  ia(Ucate  that  Prolessor  Thomas  did  not 
ordinate  to  general  pra"tice,  «honld  hardly  fail  to  overestimate  his  powers  when  he  conceived  the  idea 
have  it  on  hand  for  future  reference.— X.  Y  ifed.  ,  and  executed  the  work  of  producing  a  new  treatise 
Journ..  Jan.  1875.  npon  dlKeasieg  of  women.— HKOP.  PALLBX,  in  Louis- 

Reluctanlly  we  are  obliged  to  close  this  nnsatls-     oille  Mr.d.  Journal,  Sept.  1S71. 
factory  notice  of  so  excellent  a  work,  and  in  conclu-  I 


B 


ARNES  (ROBERT),  M.D.,  F.R.C.P., 

Obxtetric  Physician  tn  fit.  Thoma*'*  Hospital,  *c. 

A  CLIXICAL  EXPOSITION  OF  THE  MEDICAL  AND  SURGI- 
CAL DISEASES  OF  WOMEN.  Second  American,  from  the  Second  Enlarged  mvl  Revised 
English  Edition.  In  one  handsome  octavo  volume,  w  th  many  illustrations.  (In  Press.) 

QWAYNK  (JOSEPH  GRIFFITHS),  M.D., 

**J  Phyitirian-Accnitcheurtnthe  Kritt«h  ffmmil  Huftjiftnl.  *c. 

OBSTETRIC  APHORISMS  FOR  THE  USE  OF  STUDENTS  COM- 
MENCING MIDWIFERY  PRACTICE.  Second  American,  from  the  Fifth  and  Revised 
London  Edition,  with  Additions  by  E.  R.  HOTCHINS,  M.  D.  With  Illustrations.  "In  one 
neat  12mo  volume.  Cloth,  $1  25.  (Latrly  I.ntnf/1.) 

*4*  See  p.  4  of  this  Catalogue  for  the  terms  on  which  this  work  is  offered  as  a  premium  to 
subscribers  to  the  "AMERICAN  JOCRXAL  OP  THE  MKDICAI,  SCIENCES." 


H 


ODGE  (HUGH  £,.).  M.D., 

Emeritim  Professor  of  Ohntftrien ,  Ac.,  in  the  University  nf  Pennsylvania. 

ON  DISEASES  PECULIAR  TO  WOMEN;  including  Displacements 

of  the  Uterus.     With  original  illustrations.     Second  edition,  revised  and  enlarged.     In 
one  beautifully  printed  octavo  volume  of  531  pages,  cloth,  $4  50. 

From  PROF.  W.  H.  BTFORD,  of  the  Rush  Modiral     \      Professor  Hodge's  work  Is  truly  an  original  one 
College,  Chicago.  from  beginning  fo  end,  consequently  no  one  can  pe- 

The  book  bears  the  impress  of  a  master  hand,  and  I  'n(ie  iu  Pa««8  without  learning  something  new.  As  a 
must,  as  its  predecessor,  prove  acceptable  to  the  pro-  \  contribution  to  the  study  of  women  s  diseases  it  is  of 
fession.     In  diseases  of  women  Dr.  Hod**  has  estab-  j  *reat  Talne-  and  is  abundantly  able  to  stand  on  H« 
lUh»d  a  school  of  treatment  that  has  become  world-    own  ujerits.-JV.  Y.  Medical  Record,  Sept.  16,  1868. 
wide  tq  fame. 


CHURCHIM,  OX  THE  PUERPERAL  FF.VER  AND 
OTHER  DISEASES  PECULIAR  TO  WOMEJf.  1  vol. 
8vo.,pp  450,  cloth.  $2  50. 


MEIGS  OX  THE  NATCRE.  srONS,  AXD  TREAT. 
MEXT  OF  CHILDBED  FEVER.  1  vol.  8vo  ,  pp. 
•165,  cloth.  *2  00. 


HENRY  C.  LEA'S  PUBLICATIONS— (Diseases  of  Women).  23 

(JHADW1CK  (JAMES  R.),  A.M.,  M.D. 
A  MANUAL  OF  THE  DISEASES   PECULIAR  TO  WOMEN.      In  one 

neat  volume,  royal  12mo  ,  with  illustrations.     (Preparing.) 

America  has  contributed  so  largely  to  the  advances  which  have  made  the  treatment  of  Dis- 
eases of  Women  a  distinctive  department  of  medical  science,  that  the  student  will  naturally 
turn  to  American  Books  for  the  latest  and  most  trustworthy  instruction  on  the  subject  in  its 
most  modern  aspect.  Yet  there  has  thus  far  bean  no  attempt  in  this  country  to  produce  a  handy 
manual,  presenting  in  a  condensed  and  convenient  form  the  information  requisite  for  the  learne'r 
or  for  the  general  practitioner.  This  want  it  bus  been  the  effort  of  Dr.  Chadwick  to  supply,  and 
the  special  attention  which  he  has  devoted  to  the  subject  is  a  guarantee  of  the  value  of  his  labors. 
A  distinguishing  feature  of  the  work  will  be  a  number  of  diagrammatic  illustrations,  facilitating 
greatly  the  comprehension  of  the  text. 

WINCKEL  (F.), 

Professor  and  Director  of  the.  Gynaecological  Cllinic  in  the.  University  of  Rostock. 

A  COMPLETE  TREATISE  ON  THE  PATHOLOGY  AND  TREAT- 

MENT  OF  CHILDBED,  for  Students  and  Practitioners.  Translated,  with  the  consent  of 
the  author,  from  the  Second  German  Edition,  by  JAMES  READ  CHADWICK,  M  D.  In  on» 
-""tavo  volume.  Cloth,  $4  00.  (Lately  Issued  ) 


We  feel  quite  sure  that  the  profession  of  tins  country 
will  j;ive  this  interesting  and  learned  work  a  cordial 
welcome  —  Cincinnati  Mnl.  J\V:M'.<.  June.  lS7ii. 

In  iTcrmnny  this  treatise  is  regarded  HS  a  standard 
authority  in  this  branch,  of  medicine,  and  a*  it,  con- 
tains the  recent  advances  in  the  pathology  and  treat- 
ment of  disease*  that,  pertain  to  the  puerperal  condition, 
will  be  ttladly  received  hv  a  larpte  portion  of  the  profes- 
sion in  this  country. — Cincinnati  Lancet  and  Observer. 
June,  1876. 


This  work  was  written,  as  the  author  tells  us  in  his 
preface,  to  supply  a  want  arising  from  the  very  lirief 
•onsideration  jtiven  to  puerperal  diseases  by  writers  on 
'•hstetrics.  in  which  respect,  it  seems  the  profession  in 
his  country  is  not  different  from  oura.  and  tofill  a  lilank 
left  between  the  treatises  upon  the  subject  already  in 
the  field,  and  the  present  standpoint  of  science.  The 
\vork  has  reached  a  second  edition,  and  hears  evidence 
throughout  of  careful  study  and  practical  experience 
As  its  title  implies,  it  is  H  manual  rather  tlmn  a  treatise. 
— American  Journal  of  Mf.d.  Science*.  April,  1-71. 


1) 


WEST  (CHARLES),  M.D. 

LECTURES  ON  THE  DISEASES  OF  WOMEN.    Third  American, 

from  the  Third  London  edition.     In  one  neat  octavo  volume  of  about  550  pages,  clotb, 
$3  75  ;  leather,  $4  75. 

^WEES'S  TREATISE  ON  THE  DISEASES  OF  FE- 


MALES.     With  illustrations.     Eleventh  Edition, 
with  the  Author's  last  improvement?  and  correc 


ASHWELL'S  PRACTICAL  TREATISE  ON  THE  DIS- 
EASE* PECPLIAR  TO  WOMEN.  Third  American, 
from  the  Third  and  revised  London  edition.  1  vol. 


tions.     In   one  octavo  volume  of  636  nasres.  vitl  ]     Rvo.,  pp.  52S,  cloth     $3  f>0. 
plates,  ninth.     *3  on 


WANNER  (THOMAS  H.),  M.  D. 
ON  THE  SIGNS   AND  DISEASES  OF  PREGNANCY.     First  Arneric.n 

from  the  Second  and  Enlarged  English  Edition       With  four  colored  plates  andillustratioi  8 
on  wood.     In  one  handsome  octavo  volume  of  about  500  pages,  cloth,  $4  25. 


OBSTETR1CA  L  JO  URNA  L.     (Free  of  postage  for  1878  ) 
THE    OBSTETRICAL    JOURNAL   of  Great   Britain   and  Ireland; 

Including  MIDWIFERY,  nnd  the  DISEASES  OP  WOMEN  AND  INFANTS.  With  an  American 
Supplement,  edited  by  J.  V.  IXGHAM,  M.D.  A  monthly  of  about  915  octavo  pages, 
very  handsomely  printed.  Subscription,  Five  Dollars  per  annum.  Single  Numbers,  60 
oents  each. 

Commencing  with  April,  1873,  the  Obstetrical  Journal  consists  of  Original  Papers  by  Brit- 
ish and  Foreign  Contributors  ;  Transactions  of  the  Obstetrical  Societies  in  England  and  abroad  ; 
Reports  of  Hospital  Practice;  Reviews  and  Bibliographical  Notices;  Articles  and  Notes,  Edito- 
rial, Historical,  Forensic,  and  Miscellaneous;  Selections  from  Journals;  Correspondence,  Ac. 
Collecting  together  the  vast  amount  of  material  daily  accumulating  in  this  important  and  ra- 
pidly improving  department  of  medical  science,  the  value  of  the  information  which  it  pre- 
sents to  the  subscriber  may  be  estimated  from  the  character  of  the  gentlemen  who  have  already 
promised  their  support,  including  such  names  as  those  of  Drs.  ATT  HILL,  AVEI.I.NG,  ROBERT  BARNES, 
J.  HENRT  BENNET,  NATHAN  BOZEMAN,  THOMAS  CHAMBERS.  Fi.EKTWOon  CHURCHILL,  CHARLES 
CLAY,  JOHV  CLAY,  MATTHEWS  DITNCAN,  ARTHUR  FARRE,  ROBKRT  GRKENHALC.H.  GR.ULY  HEW- 
ITT, BRAXTON  HICKS,  ALFRED  MEAHOWS,  W.  LEISHMAN,  ALEX.  SIMPSON,  HEYWOOD  SMITH. 
TYLER  SMITH,  EDWARD  J.  TILT,  LAWSON  TAIT,  SPENCER  WELLS,  &c.  4c. ;  in  short,  the  repre- 
sentative men  of  British  Obstetrics  and  Gynaecology. 

In  order  to  render  the  OBSTETRICAL  JOURNAL  fully  adequate  to  the  wants  of  the  American 
profession,  each  number  contains  a  Supplement  devoted  to  the  advances  made  in  Obstetrics  and 
Gynzecology  on  this  side  of  the  Atlantic.  This  portion  of  the  Journal  is  under  the  editorial 
charge  of  Dr.  J.  V.  INGHAM,  to  whom  editorial  communications,  exchanges,  books  lor  re- 
view, Ac.,  may  be  addressed,  to  the  care  of  the  publisher. 

%*  Complete  sets  from  the  beginning  can  no  longer  be  furnished,  but  subscriptions  can  coir- 
with  January,  1878,  or  Vol.  VI.,  No.  1,  April,  1878. 


24  HENRY  C.  LBA'S  PUBLICATIONS  —  (Midwifery). 


PLA  YFAIR  (  W.  8.),  M.&.,  F.R.C.P., 
Pm/etsor  of  OMt-tric  Medicine  in  King'*  College,  etc.  etc. 

A  TREATISE  ON  TFIE  SCIENCE  AND  PRACTICE  OF  MIDWIFERY. 

Second  American,  from  the  Second  and  Revised  English  Edition.     Edited,  with  Addi- 
.  ii..i,-.  by  ROBKUT  P.  HAIIKIS,  M.D.    In  one  handsome  octavo  volume  with  numerous  illus- 

trations".    (1'rrjmriH.g  )    i 

The  rery  remarkable  success  which  fans  in  so  short  a  time  exhausted  the  first  editions  of  this 
work,  in  both  England  and  America,  shows  that  the  author  hag  successfully  supplied  an  acknowl- 
edged want  of  a  work  which,  within  a  moderate  compass,  should  serve  as  a  guide  to  th< 
recent  condition  of  obstetric  art  and  science. 

A  few  notices  of  the  previous  edition  are  appended. 

Tlie  author's  reputation  was  fuflicient  to  warrant  containing  the  ver>  latest  Information  regard  inp  the 
Breat  expecta'ions.  when  his  fo  -Incoming  work  was  an-  subject  of  ob-tetrics,  full  of  hints  of  tin-  nn-alf-t  prac- 
nounced.  anil  it."  appearance  has  caused  nodisapp.  int-  tical  value.  This  work  will  tind.  we  predict.  :t  'ar^e  ami 
uient  It  drain  in  a  masterly  way  wiih  many  disputed  >eady  sale  The  lunik  is  profusely  illti-trate.1  with  valu- 


j'oints.  and  jrives  conclusions  which  it  would  be  difficult 
to  ftain«ay.  The  work  is  the  most  valuable  acquisition 
to  the  subject  on  which  it  treats  which  has  been  Riven 


able  wood-outs,  and  is  printed  in  beautiful  type.— Cin- 
cinnati Lniirrl  unit  Oi.t'rvrr.  NOT.  1876 

This  is  pre-eminently  a  work  adapted  to  the  wants  of 


the  profession  in  a  longtime, and  in  Haying  this  we  do  ;  gtudents.  and  will  to  more  towrd  aocompli-hing  the 
not  forget  the  manv  admirable  treatises  which  have  re  pro,essjon  .,•,  \Hw.w  that  particular  branch  ,,1 •me.licin,- 
rently  appeared.  No  practitioner  onn  afford  to  be  with  thftn  „„,.  other  work  in  the  field  ofob-tetric  literature. 
outit—P,ti.niuIarJourn.,>fMrtl.,  Sept.  1876.  ln  pr.ljs,.  nf  ,llis  work  too  much  cannot  h«  said— in  «<1- 

ve:-sc  criticism  very  little      \Ve   advise  every  student 

The  hi.'h  reputation  already  won  by  T)r  Playfair  in  and  even  graduate  to  obiain  it.  and  hope,  e.re  long,  to 
this  speci.il  'lepHrtmentof  medicine  is  a  sufficient  iruar-  see  it  adopted  as  the  principal  text  boon  of  ob.stetrie 
anteo,  fur  the  meritorious  clmracterof  this  work.  Kvery  mediciue  in  every  co/lece  in  the.  United  States. — A'oji/i- 
page  is  replete  with  interesting  arid  instructive  matter-  ville  Mi'd.  and  Surg.  Journ  ,  Oct.  187U. 


E 


ODGE  (HUGH  L.),  M.  D., 

Emeritti/t  Prnfensnr  nf  Midwifery,  <frc.,  In  the  University  of  Pennsylvania,  Ac. 

THE   PRINCIPLES  AND   PRACTICE   OF   OBSTETRICS.     Illus- 

trated  with  large  lithographic  plates  containing  one  hundred  and  fifty-nine  figures  from 
original  photographs,  and  with  numerous  wood-cuts.  In  one  large  and  beautifully  printed 
quarto  volume  of  550  double-columned  pages,  strongly  bound  in  cloth,  $14. 

The  work  of  Dr.  Hodge  is  something  more  than  a 'obstetricians.  Of  the  American  works  on  the  subject 
simple  presentation  of  his  particular  views  ID  the  de-  it  is  decidedly  the  best. — Edinb.  tied.  Jour.,  Dec.  '64. 
partment  of  Obstetrics;  it  is  something  more  than  au  We  have  read  Dr.  Hodge  f-  book  with  great  plea- 
ordinary  treatise  on  midwifery  ;  it  is,  in  fact,  a  cyclo-'«ure,  and  have  much  satisfaction  In  expressing  our 
pedla  of  midwifery  He  has  aimed  to  embody  in  a  commendation  of  it  as  a  whole.  It  Is  certainly  highly 


•ingle  volume  the  whole  science  and  art  of  Obstetrics. 
AD  elaborate  text  is  combined  with  accurate  and  va- 
ried pictorial  illustrations,  so  that  DO  fact  or  principle 
Is  left  unstated  or  uoexplaioed.— Am.  Med.  Times, 
Sept.  3.  1KA4. 

It  is  very  large,  profusely  and  elegantly  illustrated, 
«nd  is  fitted  to  take  its  place  iiear  the  works  of  great 


instructive,  and  in  the  main,  we  believe,  correct.  Th« 
great  attention  which  the  author  has  devoted  to  th« 
mechanism  of  parturition,  taken  along  with  the  con- 
clusions at  which  he  has  arrived,  point,  we  thick, 
conclusively  to  the  fact  that,  In  Britain  at  least,  th* 
doctrines  of  Naegele  have  been  too  blindly  received. 
—Glasgow  Xed.  Journal,  Oct.  1864. 


***  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  an;  address,  free  by  mall, 
on  receipt  of  six  cents  in  postage  stamps. 


&AMSBOTHAM  (FRANCIS  n.),  M.D. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDI- 
CINE AND  SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged 
edition,  thoroughly  revised  by  the  author.  With  additions  by  W.  V.  KEATING,  M.D., 
Professor  of  Obstetrics,  Ac.,  in  the  Jefferson  Medical  College,  Philadelphia.  In  on«  large 
and  handsome  imperial  octavo  volume  of  650  pages,  strongly  bound  in  leather,  with  raised 
bands  :  with  sixty-four  beautiful  plates,  and  numerous  wood-cuts  in  the  text,  containing  in 
all  nearly  200  large  and  beautiful  figures.  $7  00. 


(JHURCHILL  (FLEETWOOD),  M.D.,  M.R.I. A. 

ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.     A  new 

American  from  the  fourth  revised  and  enlarged  London  edition.  With  notes  and  additions 
by  D.  FRAKCIB  CONDIK,  M.  D.,  author  of  a  "Practical  Treatise  on  the  Diseases  of  Chil- 
dren,'' Ac.  With  one  hundred  and  ninety- four  illustrations.  In  one  very  handsome  octavo 
volume  of  nearly  700  large  pages.  Cloth,  $4  00  ;  leather,  $5  00. 


MONTOOMERY'8  EXPOSITION  O?  THE  SIGNS  RIGBY'8  SYSTEM  OF  MIDWIFERY.  With  Notes 
iND  SYMPTOMS  OF  PREGNANCY.  With  two  and  Additional  Illustrations.  Second  American 
exqnisitecolored  plat«o.  and  nnmcrons  wood-cats.  [  ••IHlon.  One  Tolnme  octavo,  cloth,  422  page*. 
In  1  vol.  8vo..  of  nearly  600  pp.,  cloth.  $375.  \  $260. 


HENRY  0.  LEA'S  PUBLICATIONS — (Midwifery,  Surgery). 


25 


^EISHMAN  (WILLIAM),  M.D., 

Rugius  Professor  of  Midwifery  in  the.  University  of  Glasgow,  Ac. 

A  SYSTEM  OF  MIDWIFERY,  INCLUDING  THE  DISEASES  OF 

PREGNANCY  AND  THE  PUERPERAL  STATE.  Second  American,  from  the  Second 
and  Revised  English  Edition,  with  additions  by  JOHN  S.  PAKRY,  M.D.,  Obstetrician  to  the 
Philadelphia  Hospital,  Ac.  In  one  large  and  very  handsome  octavo  volume  ol  over  700 
pages,  with  about  two  hundred  illustrations :  cloth,  $5;  leather,  $6.  (Jnst  Issued.) 


That  thu  book  is  recommended  as  a  text-book  by 
many  of  the  leading  scholars  of  medicine  in  this 
country,  is  sufficient  evidence  of  the  favor  iu  which 
it  is  he'ld.  In  a  word,  we  know  of  no  better  book  iu 
our  language,  both  for  the  student  and  practitioner. 
The  value  of  the  book  is  enhanced  hy  this  secoud 
edition,  which  contains  many  notes  by  our  lad:  Dr. 
1'arry. — Cliicngo  Med.  Journ.  and  Examiner,  March, 
1877. 

But  the  most  valuable  additions  to  the  volume  are 
those  made  by  the  American  editor.  One  of  the  best  tests 
of  a  man's  ability  is  for  him  to  take  a  standard  work  in 
our  profession,  like  this  of  Dr.  Leisbman,  and  materially 
improve  it.  Many  a  one,  with  more  ambition  than  wis- 
dom, has  attempted  it  with  other  books  and  tailed.  But 
Dr.  Parry  has  succeeded  most  admirably.  We  know  no 
obstetrical  work  that  has  anything  better  on  the  use  of 
the  forceps  than  that  which  Dr.  Parry  has  given  in  this. 
and  no  work  that  has  the  rational  and  intelligent  views 
upon  lactation  with  which  he  has  enriched  this.  Having 
used  -'Leishman"  for  two  years  as  a  text-book  for  stu- 
dents, we  can  cordially  commend  it.  and  are  quite  satisfied 
to  continue  such  use  now. — Am.  Practitioner,  Mar.  1876. 

This  new  edition  decidedly  confirms  the  opinion  which 
we  expressed  of  the  first  edition  of  the  work-in  the  May. 
1^74,  number  of  this  Journal,  that  this  is  "the  best 
modern  work  on  the  subject  in  the  English  language." 


rbe  excellent  practiral  notes  contributed  l.y  l>r  Parry 
refer  principally  to  the  use  of  the  forceps, lactation,  anil 
t.he  puerperal  diseases,  and  are  intended  to  increase  the 
aset'ulne.-s  c.-f  the  work  in  this  country.  An  entiicly  new 
chapter  on  diphtheria  of  puerperal  wounds  haw  been 
added  (Dr.  I',  has  hud  unusual  experience  in  this  form 
of  puerperal  fever),  and  also  a  number  of  illustrations 
of  the  principal  nl>.-tct>  ieal  instruments  in  use  in  Ame- 
rica. We  have  nn hesitation  in  saying  that  the  work. in 
its  present  shape,  is  a  great  improvement  on  its  prede- 
ce~sor.  and  in  recommending  it  as  the  one  obstetrical 
text-book  which  we  should  advise  every  Kngli.-h  speak- 
ing practitioner  and  student  to  buy. — Anwrii-un  Jour- 
nal of  Obstetrics,  Feb.  1S76. 

Perhaps  the  most  useful  one  the  student  can  procure. 
Some  import  ant  additions  have  been  made  by  Ibe  editor, 
in  order  to  adapt  the  work  to  the  profession  iu  this  coun- 
try, and  some  new  illustrations  have  been  introduced, 
to  represent  the  obstetrical  instruments  generally  em- 
ployed in  American  practice.  In  its  present  form,  it  is 
an  exceedingly  valuable  book  for  both  the  student  and 
practitioner. — A'ew  York  Med.  Journal,  Jan.  187C. 

In  about  two  years  after  the  issue  of  this  excellent 
treatise  a  second  edition  has  been  called  for.  We  regard 
the  treatise  as  thoroughly  sound  and  practical,  and  one 
which  may  with  confidence  be  consulted  in  any  emtsr-' 
gency. —  The  London  Lancet,  Dec.  11,  IsTti. 


-pARRY  (JOHN  S.),  M.D., 

-*-  O'^tttrician  to  the  Philadelphia  Hospital,  Vice-Prest.  of  the  OWet.  S  ^ciety  of  Philadelphia     _ 

EXTRA-UTERINE    PREGNANCY:    ITS    CLINICAL    HISTORY, 

DIAGNOSIS,    PROGNOSIS,  AND   TREATMENT.     In  one  handsome  octavo  volume. 
Cloth,  $i  60.     (Lately  Issued.) 


It  is  with  genuine  satisfaction,  therefore,  that  weread 
the  work  before  us.  which  is  far  in  advance  of  any  mo- 
nograph upon  the  subject  in  the  English  language,  and 
exceeding  very  much,  in  the  number  of  cases  upon 
which  it  is  based,  we  believe,  any  work  of  the  kind  ever 
published.  The  author  has  given  great  care  and  study 
to  the  work,  and  has  handled  his  statistics  with  judg- 
ment: so  'hat.  whatever  was  to  be  gained  from  them, 
he  has  gained  and  added  to  our  knowledge  on  the  sub- 
ject. We  owe  the  author  much  for  giving  us  a  clear, 
readable  book  upon  this  topic.  He  has,  so  far  a*  it  is 
at  present  possible,  removed  the  obscurity  attending 
certain  points  nf  the  subject.  He  has  brought  order 


out  of  something  very  like  chaos. — Philadelphia  Mrd. 
Times,  Feb.  19,  1S76. 

In  this  work  Dr.  Parry  has  added  a  most  valuable 
contribution  to  obstetric  literature,  and  one  which  meets 
a  want  long  felt  by  those  of  the  profession  who  have 
ever  been  called  upon  to  deal  with  this  da-*  of  cases. — 
Boston  Med.  and  Surg.  Journ..  March  9, 187B. 
•  This  work,  being  as  near  as  possible  a  collection  of  the 
experiences  of  many  persons,  will  afford  a  most  useful 
guide,  both  in  diagnosis  and  treatment,  for  this  most 
interesting  and  fatal  malady.  We  think  it  should  be  in 
the  hands  of  all  physicians  practising  midwifery. — Cin- 
cinnati Clinic,  Keb.'o,  1876. 


A  SHHURST  (JOHN,  Jr.),  M.D., 

-*1  Prof  of  Clinical  Surgery,  Univ.  of  Pa.,  Surgeon  to  the  Episcopal  Hospital,  Philadelphia. 

THE   PRINCIPLES   AND   PRACTICE  OF   SURGERY.    In  one 

.very  large  and  handsome  octavo  volume-of  about  1000  pages,  with  nearly  550  illustrations, 
cloth,  $6  50;  leather,  raised  bands,  $7  50. 


Its  author  has  evidently  tested  the  writings  and 
experiences  of  the  past  and  present  in  the  crucible  j 
of  a  careful,  analytic,  and  honorable  mind,  and  faith-  _| 
fully  endeavored  to  bring  his  work  npto  the  level  of, 
the  highest  standard   of  practical  surgery. 
frank  and  definite,  and  gives  us  opinions,  and  gene 
rally  sound  ones,  instead  of  a  m&ierisujne  oft! 


jpinlons  of  others.  He  isconservative,  but  not  hide- 
bound byauthority.  His  style  isclear,  elegant,  and 
scholarly.  The  wr  rk  is  an  admirable  text-book,  and 
a  useful  book  of  reference.  It  is  a  credit  to  American 
professional  literature,  and  one  of  the  first  ripe  fruits 
>f  the  soil  fertilized  by  the  blood  of  onr  late  unhappy 
VHT.—N.  r.  Med.  Record,  Feb.  1,  1872. 


SKEY'S  OPERATIVE  SURGERY.  In  1  vol.  8vo, 
cl.,  of  650  page*  ;  withabout  lOOwood-cats  $3  2! 

COOPER'S  LECTURES  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  SuRflBRY.  Inlvol.  8vo  cloth,  750p.  $2. 

GIBSON'S  INSTITUTES  AND  PRACTICE  OF  SUR- 
OKRT.  Eighth  edition,  improved  and  altered.  With 
thirty-four  plates.  In  two  handsome  oc'.avo  vol- 
nines,  abont  1000pp.. leather. rals«dbandf.  *"  «^. 

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY. 
By  Wn.LttM  PIRRIB,  F.R  S.E.,  Professorof  Surgery 
in  the  University  of  Aberdeen.  Edited  by  JOHN 
NEILL  M.D.,  Professor  of  Surgery  in  the  Penna. 


•  Medical  College,  Surgeon  to  the  Pennsylvania  Hos- 
pital, &c.  In  one  very  baud-some  octavo  volume  of 
780  pages,  with  316  illustrations,  cloth. 

MILLER'S  PRINCIPLES  OK  SUKGKKY.  Fourth  Ame- 
rican, from  the  Third  Edinburgh  Edition.  In  one 
large  Rvo.  vol.  of  700  pages,  with  340  illustrations  •• 
cloth,  *:J  75. 

MILLEU'S  PRACTICE  OF  SURGEKY.  Fourth  Ame- 
rican, from  the  last  Edinburgh  Edition  Kevised  b; 
the  American  editor.  In  onelarge  Svo.  vo  .of  nearly 
700  pages,  with  3C4  illustrations:  cloth,  $J  16. 


26 


HJBNBY  C.  LEA'S  PUBLICATIONS — (Surgery'*. 


S1ROSS  (SAMUEL  D.),  M.D., 

Professor  of  Surgery  in  the  Jeffereon  Medical  College  of  Philadelphia. 

A  SYSTEM  OF  SURGERY:  Pathological,  Diagnostic,  Therapeutic, 

and  Operative.     Illustrated  by  upwards  of  Fourteen  Hundred  Engravings.     Fifth  edition, 
carefully  revised,  and  improved.    In  two  large  and  beautifully  printed  imperial  octavo  vol- 
umes of  about  2300  pages,  strongly  bound  in  leather,  with  raised  bands,  $16.    (Jnst  Issued.) 
The  continued  favor,  shown  by  the  exhaustion  of  successive  large  editions  of  this  great  work, 
proves  that  it  has  successfully  supplied  a  want  felt  by  American  practitioners  and  students.    In  the 
present  revision  no  pains  have  been  spared  by  the  author  to  bring  it  in  every  respect  fully  up  to 
the  day.     To  effect  this  a  large  part  of  the  work  has  been  rewritten,  and  the  whole  enlarged  by 
nearly  one  fourth,  notwithstanding  which  the   price  has  been  kept  at  its  former  very  moderate 
rate.     By  the  use  of  a  close,  though  very  legible  type,  an  unusually  large  amount  ol  matter  ii 
condensed  in  its  pages,  the  two  volumes  containing  as  much  as  .four  or  five  ordinary  octavos. 
This,  combined  with  the  most  careful  mechanical  execution,  and  its  very  durable  binding,  renders 
it  one  of  the  cheapest  works  accessible  to  the  profession.    Every  subject  properly  belonging  to  the 
domain  of  surgery  is  treated  in  detail,  so  that  the  student  who  possesses  this  work  may  be  aaid  to 
have  in  it  a  surgical  library. 


We  have  now  brought  our  task  to  a  conclusion.  Bird 
have  seldom  read  a  work  wiih  the,  practical  vi.lue  of 
which  we  have  been  more  impressed.  Kvery  chapter  is 
so  concisely  put  together,  that  the  busy  practitioner. 
when  in  dimi-ulty.  can  at  once  find  the  information  he 
require-.  His  work. on  the  eontiary.is  cosmopolitan, 
the  surgery  of  the  world  being  fully  represented  in  it. 
The  work,  in  fact,  is  so  historically  unprejudiced,  and  so 
eminently  practical,  that  it  i*  almost  a  false  compliment 
to  say  that  we  believe  it  to  be  destined  to  occupy  a  fore- 
most place  asawork  of  reference,  whileasystrm  of  mr- 
ftery  likethe  present  system  oi'surgery  is  the  practice  of 
surgeons.  The  printing  and  bimiing  of  the  work  is  uii- 
'  exceptionable;  indeed,  it  contrast-,  in  the  latter  re- 
spect, remarkably  with  Enitlish  medical  anrt  surgical 
cloth-bound  publications,  which  are  generally  so  wretch- 
edly stitched  as  to  require  re-binding  before  they  are 
any  time  in  use.— Dul>.  Journ.  nf  M?d.  Sci.,  March,  1874. 

Dr.  Gross's  Surgery,  a  great  work,  has  become  still 
greater,  both  in  sfze  and  merit,  In  its  most  recent  form. 
The  difference  in  actual  numberof  pages  is  not  more  than 
130,  but.  the  size  of  the  page  having  been  increased  to 
what  we  believe  is  technically  termed  "elephant."  there 
has  been  room  for  considerable  additions,  which,  toge- 
ther with  the  alterations,  are  improvements.— Lend. 
Lancet,  Nov.  16,1872. 

It  combines,  as  perfectly  as  possible,  the  qualities  of 
a  text-book  and  work  of  reference.  We  think  this  last 
edition  of  Gross's  '•  Surgery,"  will  confirm  his  title  of 


•'  Primut  inter  Fares."    It  is  learned,  scholar-like,  me- 
thodical, precise,  and  e-xlian-tnc.     We  scjircely  think 
any  living  man  could  write  so  complete  ami  faultless  :\ 
treiitise.  or  comprehend  more  solid,  instructive  matter, 
in  the  given  number  of  pages.     The  labor   mu.st   have 
been   immense,  and   the  work    -rives   eviileii'-" 
powers  of  mind,  and  the  highe-t  order  ofinte 
discipline  imd  methodical  disposition,  and  arrangement 
of  acquired  knowledge  and  personal  experience.—  A'.  1' 
Med  Journ..  feb  1873 

As  a  whole,  we  regard  the  work  as  the  representative 
"System  of  Surgery"  in  the  Knglish  language. — St. 
Louis  Medical  and  Surg.  JVmr/i.,  Oct.  1  - 

The  two  magnificent  volumes  before  us  afford  a  very 
complete  view  ot  the  surgical  knowledge  of  the  day. 
Some  years  ago  we  had  the  pleasure  of  presenting  the 
first  edition  of  Gross's  Surgery  to  tlie  profession  a*  » 
work  of  unrivalled  excellence;  and  now  we  time  the 
result  of  yearn  of  experience,  labor,  and  study,  all  con- 
densed upon  the  great  work  before  us  And  to  students 
or  practitioners  desirous  of  enriching  their  library  with 
a  treasure  of  reference,  we  can  simply  commend  the 
purchase  of  these  two  volumes  of  immense  research. — 
Cincinnati  Lancet  and  Observer,  Sept.  l.-7'J. 

A  complete  system  of  surgery — nr.t  a  mere  text-book 
of  operalious,  but  a  scientific  account uf  surgical  theory 
and  practiceiuall  itsdepurtments. — Jirit.und  for.  MrU.- 
C/iir.  Rev.,J»u.  1873. 


Y  THE  SAME  AUTHOR. 

A    PRACTICAL   TREATISE.  ON  THE    DISEASES,   INJURIES, 

and  Malformations  of  the  Urinary  Bladder,  the  Prostate  Olnnd,  and  the  Urethra.  Third 
Edition,  thoroughly  Revised  and  Condensed,  by  SAMUEL  W.  GROSS,  M.D.,  Surgeon  to 
the  Philadelphia  Hospital.  In  one  handsome  octavo  volume  of  574  pages,  with  ITU  illus- 
trations: cloth,  $4  50.  (Just  Issued.) 


The  book  is  fully  up  to  the  times,  and  we  know  of  no 
monograph  on  the  subject  of  urinary  diseases  that  is 
fuller  and  more  complete  than  the  one  under  notice. — 
Oincin.  Lancet  and  Observer,  Dec.  Ifc76. 

It  is  a  valuable  and  exhaustive  treatise  on  the  surgery 
of  the  urinary  organs,  brought  fully  up  to  the  exiting 
state  of  our  knowledge.  A  perusal  of  its  574  pages  will 
amply  repay  the  investigator.— 1'aajlc  Med.  and  Surf 
Journ,  Nov.  1878. 

Nothing  need  be  raid  to  commend  this  standard  work 
to  the  profession.    It  has  long  been  considered  one  of 
the  most  valuable  from  the  pen  of  the  distinguished 
author.    The  editor  bus  done  his  work  ably  and  faith- 
fully, and  several  of  the  chapters,  by  no  means  the  least  i 
useful  ones,  are  from  his  pen;  as  a  monograph  repre-  | 
senling  all  the  surgery  of  the  parts  of  which  it  ire;,  is. 
it  has  nosuperiorin  our  tongue—  Med  and  Surg  He-  I 
porter,  Oct.  21,  1876. 

For  reference  and  general  information,  the  physician 


or  surgeon  can  find  no  work  that  meets  their  necessities 
more  thoroughly  than  this,  a  revised  edition  uf  an  ex- 
cellent treatise,  and  no  medical  library  should  be  with- 
out it.  Kepli-te  with  huud.souie  ilhi-iruti  us  und  good 
ideas,  it  has  the  unusual  advantage  of  being  e.isily 
comprehended,  by  the  rca>onuble  and  practical  uinnncY 
in  which  the  various  sul.j.-ci>  ure  systematized  :u.d 
arranued  We  heartily  recommend  it  to  the  pi 
a«  a  valuable  addition  to  the  important  literature  of  dis- 
eases of  the  urinary  or^aug  —Atlanta  Med  Journ.,  Oct. 
1876. 

It  is  with  pleasure  we  now  again  tnke  up  this  old  work 
in  a  decidedly  new  dress.  Indeed,  it  must  be  regarded 
as  a  new  book  in  very  many  of  its  parts.  The  chapters 
on  -Hi-eases  of  the  liladder,"  ••  I'rostate  Body,  and 
••  Lithotomy."  are  splendid  specimens  of  descriptive 
wri'.iiiL':  while  the  chapter  on  "Stricture"  is  one  ul  the 
ni'i-t  e.,nci,e  and  clear  tlnil  we  have  ever  read  — A*w 
York  Med.  Journ.,  Nov.  1876. 


n T  TBS  SAME  AUTHOR. 

A    PRACTICAL    TREATISE    OX    FOREIGN    BODIES   IN   THE 

AIR-PASSAGES.     In  1  vol.  8vo. ,  with  illustration?,  pp.  468,  cloth,  $2  75. 
D1GELO  W  (HENRY  J.),  M  L^~ 

*-*  Professor  of  Surgery  in  the  Mct-tsichusetts  3ftd.  College. 

ON    THE   MECHANISM   OF    DISLOCATION  AND  FRACTURE 

OF  THE  HIP.     With  the  Reduction  of  the  Dislocation  by  the  Flexion  Method.     With 
numerous  original  illustrations.      In  one  very  handsome  octavo  volume.      Cloth,  $250. 


HENRY  C.  LEA'S  PUBLICATIONS — (Surgery). 


27 


(LEWIS  A  ).  A.M..  M.D., 

Snrfffon  to  the  Prfs'iyttri-in  H"x/'itnl. 

A  MANUAL  OF  OPERATIVE  SURGERY.     In  one  very  handsome 

royal  12mo.  volume  of  about  500  pages,  with  332  illustrations  ;  cloth,  $2  50.  (Just  Ready  ) 
MnnV  years  having  elapsed  since  the  nppenrance  in  this  country  of  any  work  devoted  exclu- 
sively to  the  operations  of  surgery,  and  the  ordinary  surgical  text-hooks  being  too  large  and 
unwieldy  for  ready  consultation  and  reference,  the  author  has  thought  that  a  compact  manual 
devoted  exclusively  to  practical  operative  details,  thoroughly  illustrated,  would  fupply  a  want 
universally  felt.  He  has  accordingly  sought  to  embody  in  the  work  a  concise  account  of  all  the 
operations  practised  at  the  present  day,  devoting  special  attention  to  the  newer  and  less  fami- 
liar ones,  copiously  illustrated  with  diagrams  and  figures,  man}-  of  which  are  original.  The 
scope  of  the  work  can  be  gathered  from  the  subjoined  very  condensed 


OF 

PART  I.  THE  ACCESSORIES  OF  AN  OPERATION.  PART  II.  LIGATI-RK  OF  ARTERIES.  PART  III. 
AMPUTATION.  PAHT  IV.  EXCISION  OF  JOINTS  AND  BONES  PART  V.  NETROTOMV  AND  TEHOT- 
OMY.  PART  VI.  PLASTIC  OPERATIONS  OF  i  HE  FACE.  PART  VII.  SPECIAL  OPERATIONS.  Chap. 
I.  Operations  upon  the  Eye  and  its  Ajpendages.  Chap.  II.  Operations  upon  the  Ear  and  its 
Appendages.  Chap  III.  Operations  upon  the  Mouth  and  Phaiynx.  Cluip.  IV.  Operations 
performed  upon  the  Neck.  Chap.  V  Operations  performed  upon  the  Thorax.  Chap.  VI.  Ope- 
rations performed  upon  the  Abdominal  Wall,  Stomach,  and  Intestines  Chop.  I'll  Operations 
upon  the  Male  Genit'o-Urinary  Organs  Chap.  VIII.  Operations  upon  the  Genito-Urinary 
Organs  of  the  Female.  Chap.  IX.  Miscellaneous  Operations. 


H 


'OLMES  (TIMOTHY],  M.D., 

Surgeon  to  St.  George's  Hospital,  London. 

SURGERY,  ITS   PRINCIPLES   AND   PRACTICE. 

some  octavo  volume  of  nearly  1000  pages,  with  411  illustrations      '"" 
(Just  Issued.} 


In   one  hand- 
Cloth,  $6;  leather,  $7. 


We  belie  veil  to  be  by  far  the  beet  surgical  text-booh 
tbat  we  have,  insomuch  asjt  is  the  complete*!,  and 
theonemost  thoroughlylironght  up  to  the  knowledge 
of  the  present  day.  All  who  will  givelhis  book  the 
careful  perusal  that  it  deserves  and  requires,  whe- 
ther student  or  practitioner,  will  agree  with  us,  ihst, 
from  the  happy  waj  in  which  justice  is  done,  both  to 
the  priuciples  and  practice  of  surgery,  from  thecare 
with  which  its  pages  are  brought  up  to  modern  date, 
from  the  respect  which  is  paid  all  along  t"  the  opin- 
ions of  others,  it  deserves  to  take  the  first  place 
among  the  text-books  on  surgery.  —  British  Med. 
Journ.,  Dec.  25,  1875. 

This  is  a  work  which  has  been  looked  for  on  both 
sides  of  the  Atlantic  with  much  interest.  Mr.  Holmes 
is  a  surgeon  of  large  and  varied  experience,  and  one 
of  the  best  known,  and  perhaps  the  most  biilliant 
writer  upon  surgical  snbjecrs  in  England.  I*  is  a 
book  for  students — and  an  admirable  one — and  for 
the  busy  general  practitioner.  It  will  give  a  student 
all  the  knowledge  needed  to  pass  a  rigid  examina- 
tion. The  book  fairly  justiflesthe  high  expectations 
that  were  formed  of  it.  Its  style  is  clear  and  forcible, 
even  brilliant  at  times,  and  the  conciseness  needed 


to  bring  it  within  its  proper  limits  has  uol  impaired 
its  force  and  distinctness.— A".  Y.  M«d.  Record,  April 
14,  1876. 

It  will  be  found  a  most  excellent  epitome  of  enr- 
gery  by  the  general  pracliiioner  who  ha>  nut  r  be  time 
10  give  attention  to  more  in  in  ate  and  extended  works, 
and  to  the  medical  student,  In  fact,  we  know  ofuo 
one  we  can  more  cordial  y  recommend.  The  author 
has  succeeded  well  ia  giving  a  plain  aud  practical 
a-count  of  each  surgical  injury  and  d  s»-ase,  and  of 
'  the  trentment  wWch  is  most  commonly  advisable. 
It  will  no  doubt  bee  > me  a  popular  work  in  the  pro- 
fession, and  especially  as  a  text-book.—  Cincinnati 
Med.  fftwx,  April,  1876. 

In  point  of  literary  structure  we  have  no  words  but 
j  those  of  praise  to  write  of  Dr.  Holmes'*  book.  His 
j  diction  is  always  graceful  and  clear,  aud  he  usually 
wjrks  with  great  conscientiousness.  There  is  much 
!  independence  of  thought  and  a  he«l thy  disposition  to 
j  resist  the  tendency  to  walk  in  old  tracks  simply  be- 
!  cause  they  are  old.  On  ihe  whole,  lie  has  done  his  work 
I  in  a  manner  for  which  it  would  be  ungenerous  not  to 
i  give  him  very  high  credit  indeed. — Dublin  Journ  rf 
I  Med.,  Oct.  1876. 


TJAMILTON  (FRANK  H.),  M.D., 

Professor  of  Fractures  and  Dif  locations,  Ac.,  in  Bellemie  Hasp.  Sfed.  College,  Kev>  York. 

A  PRACTICAL  TREATISE   OX  FRACTURES  AND   DISLOCA- 

TIONS.  Fifth  edition,  revised  and  improved.  In  one  large  and  handsome  octavovoluite 
of  nearly  800  pages,  with  344  illustrations.  Cloth,  $5  76:  leather,  $6  75.  (lately  Issued.) 
This  work  is  well  known,  abroad  as  well  as  at  home,  as  the  highest  authority  on  its  important 
subject — nn  authority  recognized  in  the  courts  as  well  as  in  the  schools  and  in  practice — and 
again  manifested,  not  only  by  the  demand  for  a  fifth  edition,  but  by  arrangements  now  in  pro- 
gress for  the  speedy  appearance  of  a  translation  in  Germany.  The  repeated  revisions  which  the 
author  has  thus  had  the  opportunity  of  making  have  enabled  him  to  give  the  inostcareful  consid- 
eration to  every  portion  of  the  volume,  and  he  has  sedulously  endeavored  in  the  present  issue, 
to  perfect  the  work  by  the  aid  of  his  own  enlarged  experience  and  to  incorporate  in  it  whatever 
of  value  has  been  added  in  this  department  since  the  issue  of  the  fourth  edition.  It  will  there- 
fore be  found  considerably  improved  in  matter,  while  the  most  careful  attention  has  been  paid 
to  the  typographical  execution,  and  the  volume  is  presented  to  the  profession  in  the  confident 
hope  that  it  will  more  than  maintain  its  very  distinguished  reputation. 


There  is  no  better  work  on  the  subject  in  existence 
than  that  of  Dr.  Hamilton.  It  should  be  in  the  posses 
sion  of  every  jreneral  practitioner  and  surgeon.—  The 
Am.  Journ.  of  Obstetrics.  Feb.  187C. 

The  value  of  a  work  like  this  to  the  practical  physi- 
cian and  surgeon  can  hardly  be  over-estimated,  and  the 
necessity  of  having  such  a  book  revised  to  the  latest 
dates,  not  merely  on accouut  of  the  practical  importance 


of  its  teachings,  but  also  by  reason  of  the  medico  legal 
bearings  of  the  cases  of  which  it  treats,  uud  which  have 
recently  be«n  the  subjectof  useful  papers  l>y  1'r  Hamil- 
ton and  others,  is  sufficiently  obvious  to  every  one  The 
present  volume  seems  to  amply  fill  all  the  requisites. 
\Ve  can  safely  recommend  it  as  the  best  of  its  kind  in 
the  English  language,  and  not  excelled  in  any  other. — 
Journ.  of  XeTcous  and  Mental  Disease,  Jem  1876. 


HKNBY  C.  LEA'S  PUBLICATIONS — (Surgery). 


&RICHSEN  (JOHN  E.), 

•*•'  Professor  of  Surgery  in  University  College,  London,  etc. 

THE  SCIENCE  AND  ART  OF  SURGERY;  being  a  Treatise  on  Sur- 
gical Injuries,  Diseases,  and  Operations.  Carefully  revised  by  the  author  from  the 
Seventh  and  enlarged  English  Edition.  Illustrated  by  eight  hundred  and  sixty  two  en- 
gravings on  wood.  Ir  two  large  and  beautiful  octavo  volumes  of  nearly  2000  pages: 
cloth,  $8  50  ;  leather,  $10  50.  (Now  Ready.) 

In  revising  this  standard  work  the  author  has  spared  no  pains  to  render  it  worthy  of  a  continu- 
ance of  the  very  marked  favor  which  it  has  so  long  enjojed,  by  bringing  it  thoroughly  cm  a 
level  with  the  advance  in  the  science  and  art  of  surgery  mnde  since  the  nppearnnce  of  the 
last  edition.  To  accomplish  this  has  required  the  addition  of  about  two  hundred  page"  of  text, 
while  the  illustrations  have  undergone  n  mnrked  improvement.  A  hundred  and  filty  adilitionnl 
wood-cut.*  have  been  inserted,  while  about  fifty  other  new  ones  have  been  substituted  for  figures 
which  were  not  deemed  satisfactory.  In  its  enlarged  nnd  improved  form  it  is  therefore  pre- 
sented with  the  confident  anticipation  that  it  wilt  maintain  its  position  in  the  front  rank  of 
text-bocks  for  the  student,  and  of  works  of  reference  for  the  practitioner,  while  its  exceedingly 
moderate  price  places  it  within  the  reach  of  all. 


The  seventh  edition  U  before  tlie  world  us  the  last 
word  or  surgical  science  There  may.be  monographs 
which  excel  it  upon  certain  polnix,  but  :IK  a  con 
spectiis  upon  surgical  principles  and  practice  it  is 
unrivalled.  It  will  well  reward  practitioner*  to 
read  it,  for  it  has  been  a  p'  ciiliar  province  of  Mr 
E-ichsen  to  demonstrate  the  absolute  interdepend- 
ence of  medical  and  surglcil  science  We  need 
scarcely  add,  in  conclusion,  that  w«  heartily  com- 
mend the  work  to  students  that  they  rosy  bo 
grounded  in  a  sound  faith,  and  to  practitioners  as 
an  Invaluable  guide  at  tbe  bedside — Am  Practi- 
tioner, April,  1878. 

It  in  no  i  lie  compl  ment  to  say  that  this  is  the  best 
edition  Mr.  Erich-en  has  ever  produced  of  his  well- 
known  book.  Besides  inheriting  the  virtues  of  i'8 
predecessors,  it  possesses  excellences  quite  its  own. 
Having  stated  that  Mr.  Erichsen  his  incorporated 
into  this  edition  every  recent  improvement  In  the 
science  and  art  of  surgery,  it  would  be  a  supereroga- 
tion to  give  a  detailed  criticism.  In  short,  we  un- 
hesitatingly aver  that  we  know  of  uo  other  single 
work  where  the  student  and  practitioner  can  gain  at 
oncesoclear  an  insight  into  tli.i  principles  of  surgery, 
and  so  complete  a  knowledge  of  the  exigeucies  ot 
surgical  practice.—  London  Lnncft,  Feb.  1 I,  IsT^ 

For  the  past  twenty  years  Erich«en's  Surgery  has 
maintained  its  pi  ace  as  the  leading  lex  I- book,  not  only 
in  this  country,  but  in  Great  Bri  ain.  Tint  it  is  able 
10  hold  Its  ground,  IK  abundanlly  proven  by  ibe  tho- 
roughness wi>h  which  the  pre-eLt  ••dilioii  has  he -n 
revised,  and  by  the  large  amount  of  valuable  mate- 
rial that  has  bren  addel.  Aside  from  this,  i  ne  hun- 
dred and  fifty  new  Illustration*  have  been  inserted, 
including  quite  a  nomber  of  microscopical  appear- 
ances of  pathul  .gical  processes.  So  in  irked  is  this 


change  for  the  better,  that  tbe  work  almost  appear) 
as  an  entirely  new  one — ¥i(l.  Re  <n<l,  Feb.  23,  l.sTS 

Of  the  many  treatises  on  Surgery  wl.icli  it  I. as  been 
our  task  to  study,  or  our  pleasure  to  read,  there  is  none 
which  in  all  point- ha-  -auMieil  us  howeli  :«  th-  cla--jc 
treatise  of  Kriebsen.  His  polished,  clear  style,  his  free- 
dom from  prejudice  nnd  bob!  ies.  bis  nnsni-pa^eil  crasp 
ot  his  subject,  and  vast  clinical  experience.  <jualil'\  him 
admirably  to  write  a  mo  -el  text-hook.  When  we  wish, 
at  the  least  cost  of  time,  to  learn,  the  mo.-t  of  a  topic  in 
surgery,  we  turn,  by  preference,  to  his  work.  1 1  i-  :i 
pleasure,  tberelore,  ti  see  tlilit  the  appreciation  of  it  is 
general,  and  has  led  to  tbe  appearance  of  another  edition. 
— Mtd.  and  Sutg.  J{ti»irlrr,  Feb.  2,  1S78. 

Notwithstanding  the  incn-nse  in  size,  we  observe  tbnt 
mucli  old  matter  has  l*en  omitted.  The  entire  work 
has  been  thoroughly  written  up.  and  not  merely  amend- 
ed by  a  few  extra  chapters  A  great  improvement  has 
been  made  iiAbu  il  ustrations.  One  hundred  and  fifty 
nfiw  ones  have  been  a>>ded,  and  many  cf  the  old  i  ties 
have  been  redrawn  The  author  highly  appreciates  the 
favor  wiih  which  his  work  has  been  received  by  Ameri- 
can surgeons,  and  has  endeavored  to  render  bis  latest 
edition  more  than  ever  worthy  of  their  approval.  That 
lie  has  succeeded  admirably,  musi.  we  ibink.  be  the 
geueral  opinion.  We  heartily  recommend  the  book  to 
both  student  and  practitioner. — A".  Y.  J.'e</.  .fnuntat. 
Feb. 1878. 

It  is  entirely  unpecesfar.v  for  us  to  attempt  to  add.  by 
our  praises,  one  jot  to  tbe  established  reputation  of 
Kricbsen's  Science  at.d  Art  of  Surgery.  It  bus  long 
been  a  favorite  test-book  and  authority  in  this  country 
as  w#ll  as  in  Knirhm-l  and  on  the  Continent,  and  the 
present  edition  can  but  add  to  its  popularity. —  Ohio 
Med.  Recorder,  Jan.  1878. 


T)RUITT  (ROBERT),  M.K.C.S.,#c. 

THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY. 

A  new  and  revised  American,  from  the  eighth  enlarged  and  improved  London  edition.  Illus- 
trated with  four  hundred  and  thirty -two  wood  engravings.  In  one  very  handsome  octavo 
volume,  of  nearly  700  large  and  closely  printed  pages,  cloth,  $4  00  ;  leather,  $5  00. 

practice  of  surgery  are  treated,  and  so  clearly  and 
perspicuously,  ae  to  elucidate  every  important  topic. 
We  aave  examined  the  book  most  thoroughly,  and 
can  fay  that  this  success  IB  well  merited.  His  book, 
moreover,  possesses  the  inestimable  advantages  of 
having  the  subjects  perfectly  well  arranged  and  clas- 
<ifi«d,  and  of  being  written  in  a  style  at  once  clear 
ind  succinct. — Am.  Journal  of  Jfed.  Sciences'. 


All  that  the  surgical  student  or  practitioner  could 
desire. — DtMin  Quarterly  Journal. 

It  U  a  moat  admirable  book.  We  do  not  know 
when  we  have  examined  one  with  more  pleasure. — 
Boston  Mf.d.  and  Surg.  Journal. 

In  Mr.  Diuitt's  book,  though  containing  only  some 
seven  hundred  pages,  both  the  principles  and  the 


B 


RYANT  (THOMAS),  F.R.C.S., 

Surgeon  to  Guy'*  Hospital. 

THE  PRACTICE  OF  SURGERY.  Second  American,  from  the  Sec- 
ond and  Revised  English  Edition.  With  over  Five  Hundred  Engravings  on  Wood.  In 
one  large  and  very  handsome  octavo  volume  of  nearly  1000  pages.  (Shortly.) 


ASHTON  ON  THE  DISEASES.  INJURIES.  AND  MAL- 
FORMATIONS OK  THi;  KKCTI'M  AM)  ANl'S;  with 
remarks  on  Habitnal  Constipation.  Second  Ameri- 
can, from  the  fonrth  and  enlarged  London  Edition. 
With  illustrations.  In  one  Svo  vol.  of  2S/  pages, 
cloth,*:*  25. 


SARGENT  ON  BANDAGING  AND  OTHER  OPERA- 
TIONS OF  MIXOll  ST'KGKKY.  New  edition,  with 
an  additional  chapter  on  Military  Surgery.  One 
12mo.  vol.  oJ3S3  pages,  with  18t  wood-cuts.  Cloth. 
41  75. 


29 


_  _  HENRY  C.  LEA'S  PUBLICATIONS- 
(3.0SS  EL  JN  (L.), 

Professor  of  Clinical  Surgery  in  the.  Faculty  »f  Me.,iMne,  Paris,  etc 

CLINICAL  LECTURES  ON  SURGERY.     Delivered  nt  the  Hosnitnl  of 

La  Charitc.     Translated  from  the  French  by  LEWIB  A.  STIHBON,  M.D.    Surgeon  to  the 
Presbyterian   Hosp.ta  1    New  York.     With  illusion*.     In  one  neat  oc.avo  volume  of 
350  pages  ;  cloth,  $2  oO.      (Now  Ready.)      From  the  Medical  Ktwt  and  Library 
SUMMARY  OF  CONTEXTS. 


PART  I.  SURGICAL  DTSEASRS  OF  YOCTH.  8  LKCT. 

Klt.4CT!-KKS  op  THE  LlMB*.  18 

"III.  TRAUMATIC  OSTEITIS  AXD  XKCKOSIS    2 


PART  IV.  TRAPMATTC  FKVRR,  SHPTIC^MIA 

•*N1>1'  4  LP.CT 

PART    V.    DlSK.ASKS  OK    I  UK    AKTKTI.ATIOJSg.      7 


VI.  PHI.KUMO.N,  Aii.cKSs,  AM>  PisTf'i.A.  3    " 
It  will  be  seen  from  this  brief  abstract  of  the  contents  that  these  Lectures  treat  of  «ubiectg 
which  are  of  daily  interest  to  the  i  ractitioner,  while  some  of  them  hardly  receive  in  the  text 
books  the  attention  which  t>eir  importance  deserves. 


E  (EDGAR  A.}, 

Suraeon  to  the.  Liverpool  Eye  an*  Vir  Infirmary,  nnd  tr  the  Dispensary  fnr  Skin  Disuse* 

HOW  TO  USE  THE  OPHTHALMOSCOPE.     fiein^ElementaiT  In- 

structions in  Ophthalmoscopy,  arranged  for  the  Use  of.Students.    \\Tth  thirty-five  illustra- 
tions.    In  one  small  volume  royal  ]2mo.  of  120  pages:  cloth,  $].     (JN  010  Ready.) 
This  capita]  little  work  should  be  in  the  hands  of  i  strnment  and  the  suggestions  to  aid  in  interpreting 
ev  ry  medical  student,  andwebad  almostsaid  every     whit  is  seen.—  D-troit  Hed.  Jonrn     Nov    1877 
general  practitioner.     Its  explanation  of  the  optic   1        TK«i    *• 

principles  on  which  the  ophthalmoscope  is  founded,    a,S(1  „,,,!  in^  **&**»  '"  »™T  toncise.but  we  may 

i.s  80  clear  and  simple  that  the  most  itnpld  reade  ^J^™*  25  mS'il?  ,T'  '  n"nner:  *'«"?  «' 
conld  scarcely  fail  of  understanding  them.  Equally  &£££?%?££  ^±^X  '  *?'  art.  "rl»nna.1  «"* 
satisfactory  are  tire  directions  for  the  use  of  tie  in  E.^fcd!^£  '  ^  ^  ln'lruaiT«— 


(BARTER  (R.  BRUDEXELL),  F.R.C.S 

Op'ttunliiiic  Surgeon  to  St.  George  e  Hoxpita.1,  ttc. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  EYE.    Edit- 

ed,  with  test-types  and  Additions,  by  JOHN  GREEN,  M.I),  (of  St.  Louis,  Mo.).  In  one 
handsome  octavo  volume  of  about  500  pages,  and  124  illustrations.  Cloth,  $3  75.  (Just 
Issued.  ) 

Dr.  Green,  whose  reputation  and  experience  in  this  department  are  well  known,  has  given  this 
work  a  very  careful  revision,  and  has  introduced  much  matter  which  will  be  found  of  importance 
to  the  practitioner.  As  his  system  of  test-types  i.s  the  one  recommended  by  the  author,  they 
have  been  inserted  in  the  volume  in  a  shape  which  will  admit  of  their  being  detached  and 
mounted  for  convenient  office  use. 

These  test-types,  on  a  sheet  for  mounting,  can  be  had  separate,  price  25  cents. 
It  would  be  difficult  tor  Mr.  Carer  to  write  an  uniu-    in  view,  aud  presents  the  subject  in  a  clear  mid  conn>e 
structive  book,  and  impossible  for  him  to  write  an  un-  I  manner,  easy  of  comprehension,  and  hence  the  more 
interesting  one.     Kveu  on  suljects  with  which  he  is  not     valuable.     We  would  especially  commend,  however,  as 
bound  to  be  familiar,  he  can  di.-course  with  a  raredegree    worthy  of  high  praise,  the  manner  in  which  the  thera- 
ot  clearness  aud  effect.     Our  readers  will  therefore  not  I  peutics  of  disease  of  the  eye  is  elaborated,  for  here  the 
be  surprised  to  learn  that  a  work  by  him  on  the  Llisea.-es    author  is  particularly  clear  and  practical,  where  other 
of  the  Kye  makes  a  very  valuable  addition  to  ophthal-     writers  are  unfortunately  too  often  deficient.    The  nnal 
mic  literature.  .   .  .    The  book  will  remain  one  useful     diaper  is  devoted  to  a  discus-ion  ol  the  uses  an.. 
alike  to  the  general  aud  the  special  practitioner.     Not     tion  of  spectacles,  and  is  admirably  compact,  plain,  and 
tlie  least  valuable  result  which  we  expect  from  it  is  that     useful,  especially  the  parairraj  hs  on  the  trealiin 
it  will  to  suiuecoDMderiihle  extent  despecialize  this  bril-    pres'iyopia  and  myopia.     In  conclusion,  our  thanks  ar« 
liiint  department  of  medicine.  —  London  iMnctt.  Oct.  30.    due  the  author  for  many  useful  hints  in  the  ur^at  ,-ub- 
1S75.  ject  of  ophthalmic  suritery  and   therapeutics,   a   field 

It  is  with  great  pleasure  that  we  can  endorse  the  work  »-'"™  '"  '''"•  -™lrs  wu  B1™"  b»l  ".?•"  -™.1"  ',", 
as  a  most  valuable  contribution  to  practical  ophthnl-  wheat  trom  a  u.a.-s  ul  chatJ  -.>ct«  }0ri  J/«/iCU?  7. 
mology  .  Mr.  Carter  never  deviates  from  the  end  he  has  i  Uct-  **>  1* 

1XTELLS  (J.  SOELBERG), 

'  '          Professor  of  Ophthalmology  in  King's  Vollege  Hospital,  Ac. 

A  TREATISE    ON    DISEASES  OF  THE  EYE.      Third  American, 

from  the  Fourth  nnd  Revised  London  Edition,  with  additions  ;  illustrated  with  numerous 
engravings  on  wood,  and  six  colored  plates.  Together  with  selections  from  the  Test-types 
of  Jaeger  and  Snellen.  In  one  large  and  very  handsome  octavo  volume. 


TA  URENCE  (JOHN  Z.),  F.  R.  C.  S., 

Editor  of  the  Ophthalmic  Review,  &c. 

A  HANDY-BOOK  OF   OPHTHALMIC   SURGERY,  for  the  use  o 

Practitioners.     Second  Edition,  revised  and  enlarged.     With  numerous  illustrations.     In 
one  very  handsome  octavo  volume,  cloth,  $2  75. 

TAWSON  (GEORGE],  F.  R.  C.  S.,  EngL, 

U  Assistant  Surgeon  to  the.  Royal  London  Ophthalmic  Hospital   M^orfleldf,  Ac. 

INJURIES  OF  THE  EYE,  ORBIT,  AXD  EYELIDS:  their  Imme- 
diate and  Remote  Effects.  With  about  one  hundred  illustrations.  In  one  very  hand 
some  octavo  volume,  cloth,  $3  50. 


30 


HENEY  C.  LBA'S  PUBLICATIONS — (Medical  Jurisprudence). 


PURNETT  (CHARLES  //.),  M.A  ,  M.D., 

-•-*  Aurj.1  8urg  to  the  Prztb.  hofp.,  Surgeon-in-iharpeofthrlnJIr  for  Dig.  oftlir  Enr,  Phi  In. 

TIIK    EAR,    ITS    ANATOMY.    PHYSIOLOGY,    AND    DISK  ASKS. 

A  Practical  Treatise  for  the  Use  of  Medical  Students  and  Practitioners.  In  one  h;ind- 
some  octnvo  vo'iime  of  615  pnges,  with  eighty-seven  illustrations  :  cloth,  $4  50;  leather, 
$5  50.  (Ju»t  Ready.) 

Recent  progress  in  the  investigation  of  the  structures  o*"  the  ear,  and  advances  nin'e  in  the 
modes  of  treating  its  diseases,  would  seem  to  render  desirable  a  new  wo-k  in  which  nil  the  re- 
sources of  the  molt  advanced  science  should  b»  placed  a'  the  disposal  of  the  practitioner.  This 
it  hns  been  the  aim  of  Dr.  Burnett  to  accomplish,  and  the  advantages  which  he  h.-is  enjoyed  in 
the  special  study  of  the  subject  are  :i  guarantee  that  the  result  of  hif  labors  will  prove  of  service 
to  the  profession  nt  large,  as  well  as  ti  the  specialist  in  this  department. 

As  the   t'tle  of  the  work   indicates,  this   volume      the   medical   student  and  general   practitioner,  ih's 


treats  of  the  anatomy  and  physiology  of  the  ear,  as 
well  ax  of  its  diseases,  and  the  author  has  taken 
special  palus  to  make  thin  difficult  and  complicated 
matter  thoroughly  clear  and  intelligible  The  book 
i-i  designed  w|  ecially  for  the  use  of  >tndsnts  and 
general  practitioners,  snd  places  at  their  disposal 
much  valuable  material.  Such  a  book  as  (lie  pre- 
sent one,  we  think,  has  long  been  needed,  and  we 
may  congratulate  the  author  on  his  success  in  fill- 
lug  the  gap.  Both  ir.udent  and  practitioner  can 
study  the  work  with  a  grtat  deal  of  benefit.  It  is 
prjfu'ely  and  beautifully  illustrated.— A.  T.  Hot- 
pital  Gatf.it f,  Oct  15.  lf-77. 

The  medical  student  and  general  practitioner 
have  long  felt  the  need  of  abook  ol  thit  characteron 
an  oigaa  so  litlle  understood  and  yet  so  important 
as  the  ear  The  author  ha«  presented  in  it  e  volume 
clearly  but  concisely  the  great  ad  ranc.  s  which  have 
been  made  of  laie  yearsln  otology  aud  hasitdirated 
the  direction  in  which  further  researches  can  be 
moat  profitably  carried  on  The  work  is  divided 
iuto  twop.tr  s.  In  1'art  I.  the  nnatoinv  and  physiol- 
ogy of  the  ear  ar*  minutely,  yet  explicitly,  detailed 
in  a  manner  not  10  be  found  in  auy  of  the  ordinary 
text-bjoks.  In  Part  II  the  diseases  and  treatment 
of  the  ear  are  fully  and  pracli.-ally  presented.  To 


work  is  indi-pensablfl,  and  will  not  he  found  void  of 
interest  !•>  the  specialist  — Mar^lund  Mtd.  . 
Nov  1S77 

The  appearance  of  this  book  Is  another  proof  of  the 
rapidly  increasing  amount  of  honest,  valual 
that  is  now    heing   done  in  the  various   brai 
medical  science  in  this  country.    Dr.  Burnett 
commended  for  having  wiitieu  the  be?i  book  on  the 
subject  in  the  English  language,  anl    esp-  '.i-iily  for 
the  care  and  attention  be  lias  given  to  rh    -•  ..-antic 
side  of  the  subject.— N.  Y.  Med  Jmirn.,  Do. 

There  is  probably  no  other  book  of  the  kind  in 
the  Eng'ish  language  which  contains  so  <•  -incise  and 
yet  so  complete  an  account  of  the  numer  -us  dis- 
eases to  which  the  >ar  is  liab'e.  We  can  safely  pre- 
dict that  every  intelligent  medical  man  who  takes 
the  trouble  to  make  himself  f  miliar  with  (he.  load- 
ing fact*  concerning  this  class  of  disease,  as  given 
by  Dr.  Kurnett,  will  not  only  admit  that  the  lima 
thus  employed  was  far  from  being  wattled,  but  that 
the  earnest  labors  of  Otologists  withiu  the  last  few 
years  have  taken  away  the  sting  oi  reproach  con- 
tained ia  the  hackneyed  phr»se  that '  nothing  can 
be  got  out  of  the  ear  but  fees  aud  wax.''— 
Mvi.  nnd  Sury.  Jotirn.,  Nov.  i  - 


/TAYLOR  (ALFRED  S.),  M.D., 

•*-  Lecturer  on  Med.  Jurittp.  and  Chemistry  in  Ghty't  Hospital. 

POISONS  IN  RELATION  TO  MEDICAL  JURISPRUDENCE  AND 

MEDICINE.     Third  American,  from  the  Third  and  Revised  English  Edition.     In  one 
large  octavo  volume  of  850  pages  ;  cloth,  $5  50  ;  leather,  $6  50.     (Just  Jss/ifit.) 
The  present  is  based  upon  the  two  previous  edi-      being  described  which  give   rise,  to   i  g<ti  uve.stiga- 

t  io  us  ;  "but  t  he  com  pete  revision  rendered  necessary 

by  time  has  converted  it  into  a  new  work."    This 

statement  from  the  preface  contains  all  ihat  it  is  de- 
sired to  know  in  reference  to  the  new  edition      The 

works  of  this  author  are  already  in  the  library  of 

every  phyrician  who  is  liable  to  be  called  upon  for 

medico-legal  testimony  (and  what  •  neis  not?),  so  that 

all  that  is  required  to  be  known  about  the  pret-ent 

book  is  that  the  author  has  kept  it  abreast  wuh  the 


times  What  makes  it  now,  as  always,  especially 
valuable  to  the  practitioner  is  its  conciseness  and 
practical  character,  only  those  poisonous  substances 


tions.—  The  Clinic,  Suv.  b,  1876. 

Dr.  Taylor  hat  brought  to  bear  on  the  compilation 
of  this  Vulutne,  stores  of  learning,  experii-n  e.,  and 
practical  acquaintance  wiih  J.is  »ul>>  ct,  pr.-l>;il»ly  fur 
be.yo  id  what  any  other  living  auliionty  on  toxicol- 
ogy could  have  amassed  or  utilized.  H«  Has  luily 
SUM. lined  his  refutation  by  the  conrniiiiiiHte  skill 
aud  legal  acumen  be  has  displayed  in  ti.e  an  align- 
ment of  tbe  subject-mailer,  aud  the  result  i.s  n  work 
on  Poisons  whicti  will  b«  indispensable  to  evei  y  .-i  u- 
dent  or  practitioner  in  lawaud  medicine  — Ttte  Du't- 
ImJourH.  /  M &i  He  .,  Oct.  Ia7.~>. 


B] 


THE  SAME  AUTHOR. 


undertake  to  speak  of  the  merit  of  Chilly's  Plead 
ings.— Ch'cifft,  Lf.gnl  ffrtct,  Oct.  16,  187.1. 

It  is  beyond  question  tbe  m  >»t  attractive  as  well 


MEDICAL  JURISPRUDENCE.    Seventh  American  Edition.    Edited 

by  JOHN  J.  RKESK,  M.D.,  Prcf.  of  Med.  Jurisp.  in  the  Univ.  of  Penn.     In  oue  large 
octavo  volume  of  nearly  900  pages.     Cloth,  $5  00;  leather,  $6  00.      (Lately  Ism-  -/.) 
To  the  members  of  the  legal  and  medical  profession,  .  best  authority  on  this  specialty  in  our  language.     On 
it  Is  unnecessary  to  say  anything  commendatory  of  |  this  point,  however,  we  will  -ay  that  we  c»uM<JerDr. 
Taylor's  Medical  Jurisprudence,    lie  might  as  well  '  Taylor  to  be  the  s.i-'e-i  medico-legal  authority  to  fol- 
low, in  general,  with  which  we  are  acquainted  iu  any 
language.—  Vn   tJlin.  Re.c'<rd.  Mov.  ls":J. 

as  most  reliabfe  manual  of  medical  jurisprudence    o^^^^^^?^% 

y^^&*&r~--'~ ""•"•«'  \  bsSSi^S^r  sea  ;3± 

It  is  altogethersuperfluons  for  us  to  offer  anything  j  of  the  Manual,  has  done  every;hing  to  make  his 
in  behalf  ofa  work  on  medical  jurisprudence  by  an  work  acceptable  to  his  medical  couiilrjiueu.—  Jf.  Y. 
author  who  isalmost  universally  esteemed  to  be  the  Mtd.  Record,  Jan.  15,  1S74. 

DF  THE  SAME  AUTHOR. 

THE  PRINCIPLES  AND  PRACTICE  OF  MEDICAL  JURISPRU- 
DENCE. Second  Edition.  Revised,  with  numerous  Illustrations.  In  two  large  octavo 
volumes,  cloth,  $10  00;  leather,  $12  00 

This  great  work  is  now  recognired  in  England  as  the  fullest  and  most  authoritative  treatise  on 
every  department  of  its  important  subject.  In  laying  it.  in  its  improved  form,  before  the  Ameri- 
can profession,  the  publisher  trusts  that  51  will  assume  the  same  position  in  this  country. 


HENRY  C.  LEA'S  PUBLICATION— (Miscellaneous).  31 

THOMPSON  (SIR  HENRY), 

Surgeon  and  Professor  of  Clinical  Surgery  to  University  College  Hospital 

LECTURES  ON  DISEASES  OF  THE  URINARY  ORGANS.    With 

illustrations  on  wood.     Second  American  from  the  Third  English  Edition.     In  one  neat 
octavo  volume.     Cloth,  $2  25.     (Just  Issued.) 
JjY  THE  SAME  AUTHOR.  — __ 

ON  THE  PATHOLOGY  AND  TREATMENT  OF  STRICTURE  OF 

THE  URETHRA  AND  URINARY  FISTULA.  With  plates  and  wood-cuts.  From  the 
third  and  revised  English  edition.  In  one  very  handsome  octavo  volume,  cloth  $3  50 
(  Lately  Published.) 

ft  F  THE  SA  ME  A  UTHOR. 

THE  DISEASES   OF   THE  PROSTATE,  THEIR   PATHOLOGY 

AND  TREATMENT.  Fourth  Edition,  Revised.  In  one  handsome  8vo.  vol.  o)  355  pages 
with  13  piates,  plain  and  colored,  and  illustrations  on  wood.  Cloth,  $3  75.  (Just  Issmd.) 

fTUKE  (DANIEL  HACK),  M.D  , 

Joint  author  of  "The  Manual  of  Psychological  Medicine,"  *c. 

ILLUSTRATIONS  OF  THE  INFLUENCE  OF  THE  MIND  UPON 

THE  BODY  IN  HEALTH  AND  DISEASE.  Designed  to  illustrate  the  Action  of  the 
Imagination.  In  one  handsome  octavo  volume  ol  416  pages,  cloth,  $3  25.  (Lately  Issued.) 

T>LANDFORD  (G.  FIELDING^.  D,,  f\R.  C.  P., 

Lecturer  on  Psychological  Medicine  at  the.  School  «/  St.  George's  Hospital,  Ac 

INSANITY  AND  ITS  TREATMENT:  Lectures  on  the  Treatment, 

Medicul  and  Legal,  of  Insane  Patients.  With  a  Summary  of  the  Laws  in  force  in  the 
United  Suites  on  the  Confinement  of  the  Insane.  By  ISAAC  RAY,  M.  D.  In  one  very 
handsome  octavo  volume  of  471  pages;  cloth,  $3  25. 

It  satisfies  <t  want  which  must  have  been  sorely  actually  »een  in  practice  and  the  appropriate  treat- 
felt  by  the  busy  general  practitioner*  of  this  country,  ment  tor  them,  we  find  in  Dr.  Blandford's  work  a 
It  takes  the  form  of  a  ma.una.1  of  clinical  description  considerable  advance  over  previous  writings  on  the 


of  the  various  forms  of  insanity,  with  a  description 
of  the  mode  of  examining  persons  suspected  of  in- 
sanity. We  call  particular  attention  to  this  feature 
of  the  book,  as  giving  it  a  unique  value  to  the  gene 
ral  practitioner.  If  we  pass  from  theoretical  couxide- 
r°  tions  to  descriptions  of  the  varieties  of  insanity  as 


subject.  Iris  pictures  of  the  various  forms  of  mental 
disease  are  so  clear  and  good  that  no  reader  can  fail 
to  be  struck  with  their  superiority  to  those  given  in 
•rdinary  manuals  in  the  English  Innguage  or  (so  far 
as  our  own  reading  extends;  in  any  other. — London 
Practitioner,  Feb.  1871. 


f  EA  (HENRY  C.). 

SUPERSTITION    AND    FORCE:    ESSAYS    ON    THE   WAGER   OF 

LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL,  AND  TORTURE.  Third  Revised 
and  Enlarged  Edition.  In  one 'handsome  royal  I2mo.  volume  of  about  550  pages. 
(Shortly.) 

A  few  notices  of  the  previous  edition  are  appended. 

.>  «  know  of  no  single  work  wmcu  contains,  in  ou  |  interesting  phases  of  human  society  and  progress.  .  . 
•  mall  a  compass,  so  much  illustrative  of  the  strangest  I  The  fulness  aud  breadth  with  which  he  has  carried 
operations  of  the  human  mind.  Foot-notes  give  ihe  i  out  his  comparative  survey  ol  this  repulsive  field  of 
authority  for  each  statement,  showing  vast  research  history  [Torture],  are  such  as  to  preclude  our  doing 
and  wonderful  industry.  We  advise  our  confi  erts  justice  to  the  work  within  our  present  limits,  ttui 
t  •  read  this  book  aud  ponder  its  teachings  — Chicago  here,  as  throughout  the  volume,  there  will  be  found 
Mtd.  Journal,  Aug.  1870.  |  a  wealth  of  illustration  aud  a  critical  gntsp  ol  the 

As  a  work  of  curious  inquiry  on  certain  outlying    philosophical  import  of  lacu  which  will  render  Mi. 
points  of  obsolete  law,  "Superstition  and  Force''  ii     Lea  8  labors,  overling  value  to  the  historical  olu. 
Sne  of  the  most  remarkable  books  we  have  met  with.  :  deat.-London  Saturday  Sweu,,  Oct.  s,  16,0. 
—London  Athenceum,  Nov.  3,  1866.  Ag  a  i,00ij  of  ready  reference  on  the  subject,  it  is  of 

He  has  throwna  great  deal  of  lightupon  whatmust    the  highest  value. —  Westminster  Review,  Oct.  1S67. 
be  regarded  as  one  of  the  most  instructive  as  well  as  | 


75 r  THE  SAME  AUTHOR,    (late  y  Published.) 

STUDIES  IN  CHURCH  HISTORY— THE  RISE  OF  THE  TEM- 
PORAL POWKR— BENEFIT  OF  CLERGY— EXCOMMUNICATION.  In  one  large  royal 
12ino.  volume  of  516  pp.;  oloth;  $2  75. 

The  story  was  never  told  more  calmly  or  with  ,  literary  phenomenon  that  the  head  of  one  of  the  fir»l 
greater  learning  or  wiser  thought.  We  doubt,  indeed,  '  American  houses  is  also  the  writer  of  some  of  its  most 
if  any  other  study  of  this  field  can  be  compared  with  original  books. — London  Athenceum,  Jan.  7,  1S71. 


Mr.  Lea  has  done  great  honor  to  himself  and  thit 
country  by  the  admirable  works  be  has  written  on 
ecclesiologicaland  cognate  subjects.  We  have  already 


this  for  clearness,  accuracy,  and  power.  —  Chicago 
Examiner,  Dec.  1870. 

Jlr.  Lea's  latest  work,  "StndiesinChurch  History,''    ,__„ 

fully  sustains  the  promise  of  the  first.     It  deals  with    had   occasion  to  commend    his   "Superstition    aud 
three    subjects— the    Temporal    Power,    Benefit    of    Force"   and  his  "  History  of  Sacerdotal   Celibacy." 
Clergy,  and  Excommunication,  the  record  of  which  \  The  present  volume  is  fully  as  admirable  in  its  me- 
has  a  peculiar  importance  for  the  English  student,  and  j  thodof  dealing  with  topics  and  in  the  thoroughn 
Is  a  chapter  on  Ancien;  Law  likely  to  be  regarded  as    a  quality  BO  frequently  lacking  in  American  au 
fiaal.    We  cau  hardly  pass  from  our  mention  of  such    with  which  they  are  investigated.— A".  Y.  Journal  rf 
works  as  these— with  which  that  on   "Sacerdotal    Psychol  Medicine,  July,  1870. 
Telibacy"  should  be  included — without  noting  the1 


32 


HENRY  C.  LEA'S  PUBLICATIONS. 


INDEX   TO    CATALOGUE 


American  Journal  of  tbe  Medical  Sciences 
Abstract,  Monthly,  of  tbe  Med.  Science*     . 

Allen's  Auatomy 

Anatomical  Atlas,  by  Smith  and  Homer     . 
Ashton  on  the  Kectuui  and  Anns  .        .        . 

Attfleld's  Chemistry 

Ashwell  on  Diseases  of  Females  . 

Ashhnr.-'t's  Surgery 

Browne  ou  Ophthalmoscope    .... 

Burnett  on  the  Ear 

Barues  on  Diseases  of  Women       .        .        . 

Bellamy's  Surgical  Anatomy 

Bryauts  Practical  Surgery     .... 

Bloxam's  Chemistry 

Blandford  on  insanity 

Brtslmuj  on  Keual  Diseases    .... 
Brinton  »n  the  Stomach          .... 
Bigelow  on  the  Hip          .... 
Barlow'b  Practice  of  Medicine 
Bowinan'8  (John  E.)  Practical  Chemistry   . 
Bowman's  (John  E.)  Medical  Chemistry 

Brlslowe's  Practice 

Hamatead  on  Venereal 

Bu  instead  and  Cullerier's  Atlas  of  Venereal 
Carpenter's  Human  Physiology  . 
Carpenter  on  the  Use  and  Abuse  of  Alcohol 
Cornil  and  Ranvier  , 

Carter  on  the  ty ft 

Clelaud's  Dissector 

Clowes'  Chemistry  ....'. 
Century  of  American  Medicine 
'Chadwick  on  Diseases  of  Women  . 
Charcot  on  the  Nervous  System 
Chambers  on  Diet  aud  Regimen     . 
Chambers'!)  Restorative  Medicine         .        . 
Christlson  and  Griffith's  Dispensatory 
Churchill's  System  of  Midwifery. 
Ch archill  on  Puerperal  Fever 
Condie  on  Diseases  of  Children     . 
Cooper's  (B.  B  )  Lectures  on  Surgery  .        . 
Cullerier'n  Atlas  of  Venereal  Diseases 
Cyclopedia  of  Practical  Medicine. 
Dalton's  Human  Physiology          .        . 
l>iv,s  -  Clinical  Lectures         .... 
Uewees  on  Diseases  of  Females    . 
Druttt'a  Modern  Snrgery 
DangliHon's  Medical  Dictionary    . 
Qunglison's  Hnman  Physiology    . 
Erichsen's  System  of  Surgery 
F.«r«iuhars«»ns  Therapeutics   .... 
Fenwick'8  Diagnosis  -.        . 

Flint  ou  Respiratory  Organs  . 

Flint  on  the  Heart 

Flint's  Practice  of  Medicine  . 

Flint's  Essays 

Flint  on  Phthtsi 

Flint  on  Percu**i,.n 

FothergiU's  Handbook  ofTreafment     .       ';    -'; 
Fothergill's  Antagonism  of  Therapeutic  Agents 
Pownuit's  Elementary  Chemistry  . 
Fox  on  Diseases  of  the  Skin   .       .     '.'-'.' 

Puller  on   the  Lungs.  4c 

Green's  Pathology  and  Morbid  Anatomy     . 

Gibson's  Snrgery 

G luge's  Pathological  Histology,  by  Leidy    . 

Gray's  Anatomy 

Griffith's  (R.  E.)  Universal  Formulary 
Gross  on  Urinary  Organs        .        .    '    . 
Gross  on  Foreign  Bodies  in  Air-Passages      . 
Gross's  Principles  and  Practice  of  Snrgery  . 
Oosselln's  Clinical  Lectures  on  Snrgery 
Hamilton  on  Dislocations  and  Fractures 
Bartshorne's  Essentials  of  Medicine     . 
Hartsnorne's  Conspectus  of  the  Medical  Selena 
Hart-home's  Anatomy  and  Physiology 
Hamilton  on  Nervous  Diseases 
Heath's  Practical  Anatomy    .        .  ~     .'     •;'*•' 
Hoblyn's  Medical  Dictionary        ,'*•  '»'•'    V  : 
Hodge  on  Women    .'     .        .     -»•      .'  v.-'.  o 
Hodge's  Obstetrics  .        .        .        .     ,'•#*  s--J<->> 
Hodge's  Practical  Dissections        .        .     •    . 
Holland's  Medical  Notes  and  Reflections     . 


P.V.I: 

.        1 

.        3 

7 


Ho'mes's  Snrgery 

Hnlilra  s  Landmarks     •          .... 
•iorner's  Anatomy  and  Histology 

Hudson  on  Fever 

rlill  on  Venereal  Diseases     .... 
iillier's  Handbook  of  Skin  Diseases 
fones  (C.  Haudtield)  on  Nervous  Disorders 

Kirkeh'  Physiology 

Knapp's  Chemical  Technnlogy 
Lea's  Superstition  and  Force 
Lea's  Studies  in  Church  History  . 

Lee  on  Syphilis 

Lincoln  ou  Electro-Therapeutics   . 
Leishman's  Midwifery    ..... 
La  Roche  on  Yellow  Ferer  .... 
La  Roche  on  Pneumonia,  &c. 
Laurence  and  Moon's  Ophthalmic  Surgery   . 

Lawson  ou  the  Eye 

Lehmann's  Physiological  Chemistry,  2  rols. 
Lehmann's  Chemical  Physiology  . 
Ludlow's  Manual  of  Examinations 


18    .M.Mical  News  and  Library 

1;l    Mnigs  on  Puerperal  Fever 

s    Miller's  Practice  of  Surgery 

l;i   Miller's  Principles  of  Surgery       . 

H   Montgomery  on  Pregnancy    . 

29   Neill  and  Smith's  Compendium  of  Med.  Science 

7    N'eligan's  Atlas  of  Diseases  of  the  Skin 
11    i  >b.stetrical  Journal 

•'    Parry  on  Extra-Uterine  Pregnancy 

!-'!    Pavy  on  Digestion 

I'iivy  on  Food 

s   Parrish's  Practical  Pharmncy       . 

is    pj vrie's  System  of  Surgery 

l;j    Playfair's  Midwifery 

'•'}    Qnain  and  Sharpey's  Anatomy,  by  Leidy    . 
2-    Roberts  on  Urinary  Diseases 

'•\  I  Ramsbotham  on  Parturition  • 

-"'    Remsen's  Principlesof  Chemistry 

9    Rigby's  Midwifery 

Rod  well's  Dictionary  of  Science    . 
s.imson's  Operative  Snigery 


Swayne's  Obstetric  Aphorisms      .  '      . 
Sargent's  Minor  Surgery 
Sharpey  and  Qnain's  Anatomy,  by  Leidy 
Skey's  Operative  Surgery 


!'    Slade  on  Diphtheria 

hiifer's  Histology 

li    Smith  (J.  L.)  on  Children        .... 
1 4    Smith  (H.  H.)  and  Homer's  Anatomical  Atlas 
1s    Plinth  (Edward)  on  Consumption  . 
lv    Smith  on  Wasting  Diseases  in  Children 

!•"'   Mille's Therapeutics 

]•"'    S;ill6  4  Maisch'g  Dispensatory 

Sturges  on  Clinical  Medicine          •        . 

Stokes  on  Fever 


Tanner's  Manual  of  Clinical  Medicine  . 
Tanner  on  Pregnancy 


ie 

17 
17 

1°  [Taylor's  Medical  Jurisprudence 

0  I  Taylor's  Principles  and  Practice  of  Med   Jnrisp. 
1s    Fa>  lor  on  Poisons  .  .        .        . 

1    Take  on  the  Influence  of  the  Mind 
'-•">   Thomas  ou  Diseases  of  Females    .        .        .        • 
14   Thompson  on  Urinary  Organs  . 

8   Thompson  on  Stricture 

:;   Tli.iinpson  on  tbe  Prostate 

;ti  |Todd  on  Acute  Diseases 

(i    Walshe  on  the  Heart 

(i   Watson's  Practice  of  Physic 

1'    Wells  on  th«  Eye 

:    West  on  Diseases  of  Females  ; 

1"   West  on  Diseases  of  Children 

•'    West  on  Nervous  Disorders  of  Children 

8    What  to  Observe  in  Medical  Canes 
I6    Williams  on  Consumption 

7    Wilson's  Human  Anatomy 

4    Wilson  on  Diseases  of  the  Skin     .... 

-    Wilson's  Plates  on  Diseases  of  the  Skin 
21    Wilson's  Handbook  of  Cutaneous  Medicine 

"    W. .liter's  Organic  Chemistry         . 
14    Winckel  on  Childbed 


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